The infant health effects of doulas: Leveraging big data and machine learning to inform cost-effective targeting.

Doula services represent an underutilized maternal and child health intervention with the potential to improve outcomes through the provision of physical, emotional, and informational support. However, there is limited evidence of the infant health effects of doulas despite well-established connections between maternal and infant health. Moreover, because the availability of doulas is limited and often not covered by insurers, existing evidence leaves unclear if or how doula services should be allocated to achieve the greatest improvements in outcomes. We use unique data and machine learning to develop accurate predictive models of infant health and doula service participation. We then combine these predictive models within the double machine learning method to estimate the effects of doula services. We show that while doula services reduce risk on average, the benefits of doula services increase as the risk of negative infant health outcomes increases. We compare these benefits to the costs of doula services under alternative allocation schemes and show that leveraging the risk predictions dramatically increases the cost effectiveness of doula services. Our results show the potential of big data and novel analytic methods to provide cost-effective support to those at greatest risk of poor outcomes.

Variation in the infant health effects of the women, infants, and children program by predicted risk using novel machine learning methods.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has an extensive literature documenting positive effects on infant health outcomes, specifically preterm birth, low birthweight, small size for gestational age, and infant mortality. However, existing studies focus on average effects for these relatively infrequent outcomes, thus providing no evidence for how WIC affects those at greatest risk of negative infant health outcomes. Our study focuses on documenting how WIC's infant health effects vary by level of risk. In doing so, we leverage a uniquely rich database describing maternal and infant outcomes and risk factors. Additionally, we use high dimensional data to generate predictions of risk and combine these predictions with the novel double machine learning method to stratify the effects of WIC by predicted risk. Our estimates of WIC's average treatment effects align with those in the existing literature. More importantly, we document significant variation in the effects of WIC on infant health by predicted risk level. Our results show that WIC is most beneficial among those at greatest risk of poor outcomes.

Students' consumption of high and low nutrition foods and reduced plate waste by schools' wellness-related policies and garden program participation.

BACKGROUND: Participation in school-based programs that may support children's nutritious dietary behaviours varies across schools. We examined school participation in wellness-related policies, school-based garden programs and students' dietary behaviours. METHODS: Among matching schools who did and did not participate in school-based garden programs, we analysed the lunches of 80 Pittsburgh Public Schools (PPS) students in 1st, 2nd, 6th and 7th grades during Autumn 2019 using digital food photography. We also acquired school wellness policy data. Using cross-sectional linear regression, we estimated the association between school-based garden programming, wellness-related policies and dietary outcomes, adjusting for grade. RESULTS: School's implementation of nutrition services policies was negatively associated with energy wasted from lunch ( ß = - 44.7 , p = 0.01 ${\rm{\beta }}=-44.7,{p}=0.01$ ). The number of semesters the students' school had participated in the garden program was positively associated with students' whole grain consumption ( ß = 0.07 , p < 0.001 ${\rm{\beta }}=0.07,{p}\lt 0.001$ ). CONCLUSIONS: Cross-sectional associations suggest that schools that are more engaged in wellness policies and garden programs may provide environments that are more supportive of students' nutrition than in other schools.

Tackling Persistent and Large Disparities in Birth Outcomes in Allegheny County, Pennsylvania.

OBJECTIVES: Based in Allegheny County, a coalition of local stakeholders took note of the region's infant mortality rates, particularly the stark disparities observed by race, and established a vision to reduce infant mortality in the region. The group undertook a multi-faceted effort to (1) develop predictive models of infant mortality risk; (2) evaluate the effectiveness of available interventions; and (3) combine these tools in order to tailor intervention referrals based on maternal risk profiles. With this effort, the coalition sought to address the apparent disconnect between the region's robust maternal and child health care system and relatively poor birth and infant outcomes and racial disparities. METHODS: The effort started with the integration of data from a variety of sources into an integrated database built specifically for this research effort covering the period 2003 to 2013. With the database, researchers linked each individual's data across multiple data sources, including the Allegheny County Health Department, the University of Pittsburgh Medical Center, the Allegheny County Department of Human Services Data Warehouse, and individual programs. With these data, we used a standard method for comparing outcomes and measuring the racial disparity between Black and white infants that involved calculating a ratio by dividing the rate or percentage for Black infants by the rate or percentage for white infants. RESULTS: Overall, the results showed that between 2003 and 2013 in Allegheny County disparities were more pronounced for infant mortality (3.25) than low birthweight (1.88) or preterm birth (1.49). Among the different potential causes of infant mortality, the most pronounced disparity was for SIDS (1.78). Among maternal health factors, pre-pregnancy obesity and gestational diabetes had the highest infant mortality disparity. The low birthweight disparity was similar and lower than the infant mortality disparity across all of the maternal health factors, while the preterm birth disparity was even lower. For the maternal behavioral and contextual factors, the infant mortality disparity ranged from 1.5 to 2.3. CONCLUSION: The 11-year span of data reported in the IMPreSIv database and the breadth of intervention data included allowed us to report granular information on birth outcomes within Allegheny County over this time period. The database also allowed us to summarize the various factors associated with the range of birth outcomes and describe the participation rates in the medical and community setting interventions. Against this backdrop of pronounced disparities in birth outcomes across a range of factors, we examined the effectiveness of interventions for women with different risk factors (e.g. substance use disorders) in order to develop a tool to facilitate individualized referrals to the interventions that will help the most for a specific risk profile.

United States Doula Programs and Their Outcomes: A Scoping Review to Inform State-Level Policies.

BACKGROUND: The field of maternal health has advanced significantly over the past decades. However, the United States continues to have poor outcomes in comparison with other industrialized nations. With emerging evidence on the promise of doula care, states are including doula care under their Medicaid programs. METHODS: We conducted a scoping review across four academic databases and gray literature published between January 1, 2012, and March 10, 2022, to describe the landscape of literature on U.S. doula programs and their outcomes in order to inform state policy makers considering laws or programs related to doula care. FINDINGS: Of 740 records identified, 100 met inclusion criteria. Outcomes fell into four areas: birthing people's outcomes, infant outcomes, systems of care and implementation, and cross-cutting issues. Data on outcomes related to doula care in the literature were predominantly clinical, even though doulas are not clinical providers. Although some studies have found associations between doula care and improved clinical outcomes for birthing people and infants, the evidence is limited due to small sample sizes, study methodology, or conflicting conclusions. Doula outcomes are underexplored in the literature, with mainly qualitative data describing low levels of diversity and equity within the doula workforce and ineffective payment models. When cost-effectiveness estimates have been calculated, they largely rely on savings realized from averted cesarean births, preterm births, and neonatal intensive care unit admissions. CONCLUSIONS: As state Medicaid programs expand to include doula care, policymakers should be aware of the limitations in the evidence as they plan for successful implementation, such as the narrow focus on certain clinical outcomes to quantify cost savings and conflicting conclusions on the impact of doula care. An important consideration is the impact of the reimbursement rate on the adoption of doula care, which is why it is important to engage doulas in compensation determinations, as well as the development of improved metrics to untangle the components that contribute to maternal health outcomes in the United States.

The relationship between protective factors and outcomes for children exposed to violence.

To develop prevention and intervention programs for children exposed to violence, it is necessary to understand what factors might help alleviate the negative effects of violence exposure. In this study, we sought to test whether relationships exist between certain protective factors and subsequent adjustment and to examine whether violence re-exposure contributed to changes in outcomes over time. The analyses revealed that caregiver reports of both child self-control and the quality of the parent-child relationship were related to changes in child posttraumatic stress disorder (PTSD) symptoms and behavior problems. Furthermore, children experiencing more categories of violence re-exposure had increased behavior problems at follow-up compared to those without re-exposure. These findings advance our understanding of the relationship between these protective factors and outcomes for children exposed to violence and suggest that intervening to bolster these protective factors could improve outcomes.

Improving Support for Veteran Women: Veterans' Issues in Focus.

Women's military experiences and post-service needs often differ from those of men. More research focused on this population will help ensure that policies and programs adequately support veteran women's transitions from military to civilian life.

A Needs Assessment of Women Veterans in Western Pennsylvania: Final Report to Adagio Health.

Women make up an increasingly large share of the U.S. veteran population, and their numbers continue to grow while the overall number of veterans is on the decline. Yet programs designed to support veterans' health and well-being have largely focused on men. Women's military experiences and postservice needs often differ from those of men, and women veterans also differ in significant ways from their nonveteran counterparts. Few studies have explored these variations, and this has translated to potentially missed opportunities to improve support for women during and after their transition from military to civilian life. Adagio Health, a provider of health, wellness, and nutrition services based in Western Pennsylvania, has taken steps to improve care for women veterans in its service area. To identify opportunities to further expand and enhance Adagio Health's efforts to support women veterans' health and wellness, the authors quantitatively and qualitatively assessed the needs of women veterans in the Adagio Health service area. The assessment provides a clearer picture of this often-underserved population, available services and resources, gaps in support, barriers to access, and areas to prioritize to provide the best support possible for the health and well-being of women who served. With the approaches recommended in this assessment, Adagio Health can continue increasing its capacities and capabilities for supporting its women veteran patients and making progress toward its goal of advancing their health and well-being.

The effects of Arkansas master settlement spending on disparities in smoking.

OBJECTIVES: We assessed the effect of Master Settlement Agreement (MSA) spending on smoking disparities in Arkansas, which distinguished itself from other states by investing all of its MSA funds in health-related programs. METHODS: In 1996-2009 data from the Behavioral Risk Factor Surveillance System, we specified multivariate logistic models to examine gender and racial/ethnic disparities in smoking rates within Arkansas (a pre-post analysis) and between Arkansas and its 6 neighboring states. RESULTS: Before the MSA programs started in 2001, male Arkansans smoked more than did female Arkansans (P < .05). After the programs, smoking declined significantly among men (but not women), eliminating the gender disparity by 2009. Smoking among men in Arkansas also declined more than it did in neighboring states (P < .05). Hispanics showed a greater decline in smoking than did non-Hispanic Whites in Arkansas (but not in neighboring states). In 2001, Hispanic Arkansans smoked more than did non-Hispanic Whites (P < .05); by 2009, Hispanic Arkansans smoked significantly less than did non-Hispanic Whites (P < .05). CONCLUSIONS: MSA-funded programs were more effective in some segments of the Arkansas population than in others. Policymakers should consider targeting future MSA tobacco control programs to populations most resistant to change.

The Agency for Healthcare Research and Quality's children's health research portfolio.

The objective of this work was to describe and assess the potential impact of the Agency for Healthcare Research and Quality's, AHRQ's, children's health activities. Using AHRQ databases and publications lists and generic search engines, we developed a comprehensive list of AHRQ's funded children's health activities (1990-2005) and related publications (1996-2002). We conducted bibliometric analyses and used Stryer's (2000) approach to categorize their potential impact. We found that AHRQ's child health portfolio has changed over time with an increase in activities related to patient safety and health information technology, reflecting trends at AHRQ as a whole. Further, AHRQ has contributed a substantial body of new knowledge as a result of its funding for children's health activities. The bibliometric analysis suggests that AHRQ's children's health activities have successfully disseminated research findings and new knowledge through the published literature. Most of the publications present research findings that can be building blocks early in the translation continuum rather than findings that directly inform policy or change clinical practice. Through its funding of children's health activities, AHRQ has contributed new knowledge that has been disseminated effectively in the published literature. However, while AHRQ has successfully engaged the child health services research community, efforts to broaden into policy, practice and patient arenas have been less successful.

Evaluation of the Connections to Care (C2C) Initiative: Interim Report.

At least one in five adult New Yorkers is likely to meet the criteria for a mental health diagnosis, yet most do not receive mental health services to treat these problems. Mental health problems, such as depression and anxiety, disproportionately affect historically underserved segments of the population, such as racial/ethnic minority and low-income individuals, and these groups are least likely to receive mental health services. The Connections to Care (C2C) Collaborative developed the C2C program, which integrates mental health support into the work of nonclinical community-based organizations (CBOs) through task shifting; task shifting is an approach extending evidence-informed health care skills to community-based partners under the oversight of trained professionals to expand the health care workforce. This study uses data from interviews, surveys, and CBO-provided progress indicators to describe how C2C has been implemented within and across the 15 CBOs. This study also describes study methods and a description of the baseline sample for the impact evaluation at the time of writing.

Youth victimization profiles and change in mental health symptoms over one year.

OBJECTIVE: To understand how youth PTSD symptoms and externalizing problems emerge and change over time for youth with different profiles of victimization, including polyvictimization. METHOD: We conducted a latent class analysis (LCA) to identify empirically derived victimization profiles in a sample of 2,776 youth who participated in an evaluation study. We then conducted growth curve analyses to determine whether these victimization profiles predicted change in the course of PTSD symptoms and externalizing problems over a 1-year time period for youth engaged in a variety of community-based services. RESULTS: The LCA revealed three profiles: a low victimization profile defined by relatively low endorsement of victimization across types; a witnessing profile defined by particularly high endorsement of witnessing violence; and a polyvictimization profile defined by high endorsement of multiple types of victimization. We found that overall, despite differing initial levels of PTSD symptoms and externalizing problems, all three groups' symptoms improved over the year, but the polyvictimization class generally showed the steepest decreases, particularly in caregiver-reported PTSD symptoms. CONCLUSION: Polyvictimized youth participating in community-based services are at increased risk for developing PTSD and externalizing problems, but symptoms appear to decrease to levels similar to other victimized youth after one year. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Advancing institutional efforts to support research mentorship: a conceptual framework and self-assessment tool.

The purpose of this article is to assist institutions in advancing their efforts to support research mentorship. The authors begin by describing how institutions can shape the key domains of research mentorship: (1) the criteria for selecting mentors, (2) incentives for motivating faculty to serve effectively as mentors, (3) factors that facilitate the mentor-mentee relationship, (4) factors that strengthen a mentee's ability to conduct research responsibly, and (5) factors that contribute to the professional development of both mentees and mentors. On the basis of a conceptual analysis of these domains as currently documented in the literature, as well as their collective experience examining mentoring programs at a range of academic medicine institutions and departments, the authors provide a framework that leaders of institutions and/or departments can adapt for use as a tool to document and monitor policies for guiding the mentorship process, the programs/activities through which these policies are implemented, and the structures that are responsible for maintaining policies and implementing programs. The authors provide an example of how one hypothetical institution might use the self-assessment tool to track its policies, programs, and structures across the key domains of research mentorship and, on the basis of this information, identify a range of potential actions to strengthen its research mentoring efforts. The authors conclude with a brief discussion of the limitations of the self-assessment tool, the potential drawbacks and benefits of the overall approach, and proposed next steps for research in this area.

Improving Child Welfare Outcomes: Balancing Investments in Prevention and Treatment.

To provide objective analyses about the effects of prevention and treatment programs on child welfare outcomes, RAND researchers built a quantitative model that simulated how children enter and flow through the nation's child welfare system. They then used the model to project how different policy options (preventive services, family preservation treatment efforts, kinship care treatment efforts, and a policy package that combined preventive services and kinship care) would affect a child's pathway through the system, costs, and outcomes in early adulthood. This study is the first attempt to integrate maltreatment risk, detection, pathways through the system, and consequences in a comprehensive quantitative model that can be used to simulate the impact of policy changes. This research suggests that expanding both prevention and treatment is needed to achieve the desired policy objectives: Combining options that intervene at different points in the system and increasing both prevention and treatment generates stronger effects than would any single option. The simulation model identifies ways to increase both targeted prevention and treatment while achieving multiple objectives: reducing maltreatment and the number of children entering the system, improving a child's experience moving through the system, and improving outcomes in young adulthood. These objectives can all be met while also reducing total child welfare system costs. A policy package combining expanded prevention and kinship supports pays for itself: There is a net cost reduction in the range of 3 to 7 percent of total spending (or approximately $5.2 billion to $10.5 billion saved against the current baseline of $155.9 billion) for a cohort of children born over a five-year period.

Improving Outcomes for Children Exposed to Violence: Safe Start Promising Approaches.

Children's exposure to violence is common and can lead to mental health problems and delinquent behaviors. Because many interventions have focused on specific violence types or symptoms and been difficult to implement in real-world settings, the evidence base is still emerging. The Office of Juvenile Justice and Delinquency Prevention's Safe Start Promising Approaches (SSPA) initiative focused on preventing and reducing the impact of children's exposure to violence through interventions in ten diverse communities. The evaluation examined the effectiveness of the SSPA interventions to address issues for children and families exposed to violence. The ten sites were diverse in their intervention approaches, types of violence exposure targeted, and implementation settings. To evaluate each approach's effectiveness in reducing violence's harmful effects, RAND researchers partnered with the community-based sites to develop a rigorous controlled evaluation design for each intervention, with either a randomized control group or a comparison group selected on similar characteristics. The longitudinal analyses found that families in both the intervention and comparison groups had positive gains on many outcomes, but there was no evidence that the intervention groups improved more. Among those who received Safe Start services, one site produced large, significant improvements in posttraumatic stress disorder symptoms, and another site produced medium, significant effects on several outcomes (child self-control, posttraumatic stress disorder, and behavior; caregiver depression; and family conflict). Although the initiative added to knowledge about how to address the problem, there was no clear case for using a particular intervention to help these children and their families.

Child protection and justice systems processing of serious child abuse and neglect cases.

OBJECTIVE: The aim of this study was to examine the trajectory of cases through four systems: child protection, law enforcement, the dependency courts, and the criminal courts. METHOD: This study focused on a county selected from a 41-county telephone survey conducted for the National Incidence Study of Child Abuse and Neglect (NIS-3). For this analysis prospective samples were drawn from law enforcement (n=225) and the county child protection (CPS) agency (n=225) and followed through in-depth case tracking across all agencies and through both the dependency and criminal court systems. RESULTS: The percentage of CPS cases opened in dependency court was similar to prior studies (29%), but the acceptance and prosecution rates were much higher--92% of the cases referred from CPS, including many cases of physical abuse. Compared to referrals from CPS to law enforcement (93%), few cases were referred from law enforcement to CPS (17%). Anecdotally, case referral patterns appeared to be influenced by communication patterns and mutual positive regard, regardless of the collaborative protocols in place. One of the most instructive findings was the degree of difficulty in tracking cases across organizations and the types of obstacles that impeded success. Disorganization was not an issue, rather internal structures set up to facilitate intra-organizational processing were the same structures that actually impeded cross-organizational case finding. CONCLUSIONS: It is not sufficient to rely on the existence of multi-disciplinary teams or Child Advocacy Centers to ensure collaboration. More attention to daily tasks and activities as well as the nature and quality of communication is warranted. On the technical side, use of common case identifiers on cases that are cross-referred is strongly recommended. Future studies should broaden the scope of inquiry to include the consequences of all case trajectories, rather than solely focusing on the justice system.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

Mental Health Retrosight: Understanding the Returns From Research (Lessons From Schizophrenia): Policy Report.

This study examines the impacts arising from neuroscience and mental health research going back 20-25 years, and identifies attributes of the research, researchers or research setting that are associated with translation into patient benefit, in the particular case of schizophrenia. The study combined two methods: forward-tracing case studies to examine where scientific advances of 20 years ago have led to impact today; and backward-tracing perspectives to identify the research antecedents of today's interventions in schizophrenia. These research and impact trails are followed principally in Canada, the UK and the USA. The headline findings are as follows: The case studies and perspectives support the view that mental health research has led to a diverse and beneficial range of academic, health, social and economic impacts over the 20 years since the research was undertaken.Clinical research has had a larger impact on patient care than basic research has over the 20 years since the research was undertaken.Those involved in mental health research who work across boundaries are associated with wider health and social benefits.Committed individuals, motivated by patient need, who effectively champion research agendas and/or translation into practice are key in driving the development and implementation of interventions.This study provides an overview of the methods and presents the full set of findings, with the policy provocations they raise, and an emerging research agenda. It has been written for funders of biomedical and health research and health services, health researchers, and policymakers in those fields. It will also be of interest to those involved in research and impact evaluation.

Interventions to Reduce Mental Health Stigma and Discrimination: A Literature Review to Guide Evaluation of California's Mental Health Prevention and Early Intervention Initiative.

A number of programs aim to reduce the stigma and discrimination associated with mental illness, and they can include a variety of components such as training, education, media campaigns, and contact with people with mental illness. Stigma and discrimination reduction activities are evaluated in this article, using evidence from an extensive literature review. Specific areas reviewed include relevant theories of stigma and prejudice reduction, what is and is not known about the effectiveness of various approaches to reducing the stigma of mental illness, the kinds of methodologies previously used in evaluating these approaches, and the methodologies that should be employed in the future. The authors also introduce a conceptual model of mental health stigma reduction based on a variety of existing theories and evidence.

How much does "how much" matter? Assessing the relationship between children's lifetime exposure to violence and trauma symptoms, behavior problems, and parenting stress.

The study explores whether and how lifetime violence exposure is related to a set of negative symptoms: child internalizing and externalizing behavior problems, child trauma symptoms, and parenting stress. Using a large sample of violence-exposed children recruited to participate in intervention research, the study employs different methods of measuring that exposure. These include total frequency of all lifetime exposure, total frequency of lifetime exposure by broad category (i.e., assault, maltreatment, sexual abuse, and witnessing violence), and polyvictimization defined as exposure to multiple violence categories. The results indicate that only polyvictimization, constructed as a dichotomous variable indicating two or more categories of lifetime exposure, emerged as a consistent predictor of negative symptoms. The total lifetime frequency of all violence exposure was not associated with negative symptoms, after controlling for the influence of polyvictimization. Likewise, in the presence of a dichotomous polyvictimization indicator the total lifetime frequency of exposure to a particular violence category was unrelated to symptoms overall, with the exception of trauma symptoms and experiences of sexual abuse. Taken together, these findings suggest that total lifetime exposure is not particularly important to negative symptoms, nor is any particular category of exposure after controlling for polyvictimization, with the single exception of sexual abuse and trauma symptoms. Instead, it is the mix of exposure experiences that predict negative impacts on children in this sample. Further research is needed to continue to explore and test these issues.