Association between low health literacy and adverse health behaviors in North Carolina, 2016.

Introduction: Health literacy (HL) is an urgent public health challenge facing the U.S. HL is a critical factor in health inequities and exacerbates underlying social determinants of health. Purpose: This study assesses the association between low HL (LHL) and adverse health behaviors, which contribute to poor health. Methods: Researchers used North Carolina's 2016 Behavioral Risk Factor Surveillance System data, namely, the Health Literacy optional module which asks respondents to rate how difficult it is for them to get health-related advice or to understand medical information (verbal or written). Health behaviors analyzed were excessive alcohol consumption, lack of adequate exercise and sleep, and irregular medical and dental check-ups. The sample was divided into four age categories (18-49, 50-64, and 65-75, and 76 and older) for statistical comparisons. Stata 15 and a user-written Stata command, - psacalc-, were used to examine the relationships by addressing omitted variable bias in OLS regressions. Results: Findings indicate that LHL has a direct robust relationship with not exercising, inadequate sleep, irregular health and dental checkup, and health screenings across different age groups. Among women, LHL is associated with getting a Pap test in 3 years as opposed to more than 3 years. Implications: The adverse behaviors can explain the mechanisms underlying the link between LHL and adverse health outcomes. Further research on the causal relationship between LHL and adverse health behaviors using longitudinal data on a broader geographic region is warranted.

Association Between Perinatal Mental Health and Pregnancy and Neonatal Complications: A Retrospective Birth Cohort Study.

BACKGROUND: Maternal mental health as an important precursor to reproductive and neonatal complications remains understudied in the United States, particularly in the Southeastern region, despite high medical costs, maternal morbidity, and infant burden. This study sought to estimate the incidence of perinatal mental health disorders and the associated increased risk of leading pregnancy and infant complications. METHODS: A population-based retrospective birth cohort of childbirth hospitalizations and readmissions was constructed for women in South Carolina, 1999 to 2017. Prevalence rates were calculated for perinatal mood and anxiety disorders (PMAD), severe mental illness, and mental disorders of pregnancy (MDP). Poisson regression models using generalized estimating equations were used to estimate adjusted relative risks for the association between mental health conditions and severe maternal morbidity, hypertensive disorders of pregnancy, gestational diabetes, cesarean section, preterm birth, and low birthweight. RESULTS: The most prevalent maternal mental condition was MDP (3.9%), followed by PMAD (2.7%) and severe mental illness (0.13%). PMAD was associated with a higher risk of severe maternal morbidity, hypertensive disorders of pregnancy, and cesarean section, as well as a higher risk of preterm birth and low birthweight infants. Severe mental illness was associated with low birthweight, hypertensive disorders of pregnancy, and cesarean section. Pregnant populations with MDP were more at risk for severe maternal morbidity, preterm birth, hypertensive disorders of pregnancy, low birthweight, and cesarean section. Each maternal mental health outcome was associated with an increased risk for hospital readmissions up to 45 days after childbirth. CONCLUSIONS: Results demonstrate the escalating burden of PMAD and MDP for pregnant populations over time, with important consequences related to maternal and infant morbidity.

Nutrition Practitioner Perceptions of Nutrition Education with Pregnant Clients.

OBJECTIVE: Nutrition education during pregnancy is associated with improved maternal and fetal outcomes. This study explored nutrition practitioner perceptions of providing nutrition education to this population and examined gaps in current practices. METHODS: North Carolina nutrition practitioners (n = 73) working with pregnant women were asked to complete a survey about their provision of nutrition services to pregnant clients. Data were analyzed for descriptive statistics. RESULTS: Cost (91%) and lack of time to cook (83%) were perceived as the largest barriers for clients to making dietary changes. Topics most requested by clients paralleled those practitioners identified as needs: weight gain (69%), lactation (63%), and general nutrition information (57%). Pamphlets (97%), posters (66%), telehealth (42%), and texting (38%) were accepted education methods. CONCLUSIONS AND IMPLICATIONS: Evidence-based education on weight, lactation, and general nutrition, using time and cost-efficient approaches, and embracing technology were desired by pregnant clients when receiving nutrition education from nutrition and other health care practitioners and may result in improved maternal and fetal outcomes.

School Nutrition Director Perceptions of Flexible Regulations for School Nutrition Programs in One Southeastern State.

BACKGROUND: Schools are a promising site for influencing the dietary intake of children and adolescents. The US Department of Agriculture recently released flexibilities to requirements for whole-grains, sodium, and low-fat milk in schools who demonstrated difficulty meeting nutrition standards for school meal programs. The support of School Nutrition Directors (SNDs) is vital to the success of school food environment changes; however, few studies have explored SNDs perceptions to changes in nutrition standards. METHODS: Experiences and perspectives toward nutrition standards of 10 SNDs, and their satisfaction with flexibilities for whole-grains, sodium, and low-fat milk were explored using a semi-structured interview. Responses were analyzed using an inductive approach with thematic analysis. RESULTS: Three broad categories emerged challenges with the Healthy, Hunger-Free Kids Act, food preferences and acceptability, and support and representation. A greater need for internal and external support, assistance in equipment and staff, procurement of foods compliant with regulations and acceptable to students, and more input on federal decisions and policies were perceived as important. CONCLUSIONS: Results provide critical insight into the implementation of nutrition standards. Future research and changes to school nutrition programs should consider these challenges as they strive to meet the needs of this important population.

Adverse Childhood Experiences among Adults in North Carolina, USA: Influences on Risk Factors for Poor Health across the Lifespan and Intergenerational Implications.

Adverse childhood experiences (ACEs) are a critical determinant and predictor of health across the lifespan. The Appalachian region of the United States, particularly the central and southern portions, experiences worse health outcomes when compared to the rest of the nation. The current research sought to understand the cross-sectional relationships between ACEs, social determinants of health and other health risk factors in one southcentral Appalachian state. Researchers used the 2012 and 2014 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) for analyses. An indicator variable of Appalachian county (n = 29) was used to make comparisons against non-Appalachian counties (n = 71). Analyses further examined the prevalence of ACEs in households with and without children across Appalachian and non-Appalachian regions, and the effects of experiencing four or more ACEs on health risk factors. There were no statistically significant differences between Appalachian and non-Appalachian counties in the prevalence of ACEs. However, compared with adults in households without children, those with children reported a higher percentage of ACEs. Reporting four or more ACEs was associated with higher prevalence of smoking (prevalence ratio [PR] = 1.56), heavy alcohol consumption (PR = 1.69), overweight/obesity (PR = 1.07), frequent mental distress (PR = 2.45), and food insecurity (PR = 1.58) in adjusted models and with fair or poor health only outside Appalachia (PR = 1.65). Residence in an Appalachian county was independently associated with higher prevalence of food insecurity (PR = 1.13). Developing programs and implementing policies aimed at reducing the impact of ACEs could improve social determinants of health, thereby helping to reduce health disparities.

Prevalence and domains of disability within and outside Appalachian North Carolina: 2013-2016 Behavioral Risk Factor Surveillance System.

BACKGROUND: The health and social conditions of the Appalachian region generally are poorer than in the US overall, and this gap is widening, suggesting disability may be higher in Appalachia. OBJECTIVE: To describe the prevalence of disability overall and by domain in Appalachian and non-Appalachian regions in North Carolina (NC) and describe the characteristics of people with and without disability in each region. METHODS: We conducted a cross-sectional study using data from the NC Behavioral Risk Factor Surveillance System from 2013 to 2016 which assessed disability in five domains: vision, cognitive, mobility, self-care, and independent living. We calculated weighted proportions and age- and sex-adjusted prevalence using direct standardization to the 2010 Census. RESULTS: The prevalence of disability in Appalachian NC was significantly higher than in non-Appalachian NC after standardizing by age and sex (26.6% in Appalachia, 24.1% outside Appalachia, p < 0.001). In both regions, mobility disability was most common and self-care disability was least common. People within Appalachia more frequently reported disability in all domains compared to people outside Appalachia. CONCLUSIONS: More than one in four adults in Appalachian North Carolina experience disability in at least one domain and one in eight experiences disability in multiple domains. The high prevalence of disability should be considered when planning programs and services across the spectrum of public health. Understanding common disability domains present in populations can inform public health agencies and service providers and help them develop programs and messaging that meet the needs of residents in Appalachia and are accessible to people with disabilities.

Impact of Breakfast in the Classroom on Participation and Food Waste.

OBJECTIVE: To investigate differences in school breakfast participation and food waste in 1 school district before and after the adoption of Breakfast in the Classroom. METHODS: Using a pretest-posttest design, participation and food waste were measured from 7 elementary schools in a rural area of southwest Virginia during the 2014-2015 school year. Participation and waste were measured on 4 days in each school (twice before and twice after Breakfast in the Classroom implementation) using the quarter-waste method. RESULTS: Across all schools, food waste decreased from 43.0% to 38.5% with Breakfast in the Classroom, with significant decreases for entrée items, juice, and savory snack foods (P < .01). Fruit and cheese items generated the greatest amount of food waste at 58.2% and 49.0%, respectively. CONCLUSIONS AND IMPLICATIONS: Breakfast in the Classroom may be an effective tool to decrease food waste while improving dietary intake. Future research is needed among more diverse populations.

Coresidence with mother-in-law and maternal anemia in rural India.

In a highly patriarchal society such as India, and many Middle Eastern, African, and East Asian countries, coresidence with the mother-in-law is ubiquitous during the early years of marriage. During the period when women have to make crucial fertility decisions, they are under the supervision of the mother-in-law. Using the National Family Health Survey 2005-2006, and estimation strategies such as propensity score (PS) weighted regressions and a difference-in-differences type approach with PS matching, we estimate the causal effect of coresidence during pregnancy on maternal anemia among rural women in India. Here, coresidence and non-coresidence during pregnancy define our treatment and control, respectively. Women coresiding with both in-laws had fewer children, were younger, more educated, wealthier, and less likely to be Muslim and from scheduled castes and tribes compared to non-coresident women. Results indicate that the mother-in-law is a potentially valuable resource during pregnancy. For example, living with the mother-in-law reduced the likelihood of moderate to severe anemia by 13.2 percentage points compared to no coresidence. Under joint coresidence with both in-laws, the effect dropped to 8.5 percentage points. Moreover, women living with the mother in-law were 16.8 percentage points more likely to receive any iron supplementation. From a public health perspective and for policy making, the results indicate that safe motherhood programs should be augmented with awareness generation components which target the mother-in-law. Furthermore, pregnant women in nuclear families need particular attention.

Adult Food Security and the Relationship with Adverse Childhood Experiences Among Residents of Appalachian North Carolina.

Introduction: The Appalachian region has worse health outcomes than the remainder of the United States. These disparities are often linked to the underlying social and environmental determinants of health. Adverse childhood experiences (ACEs) are associated with poor health outcomes across the lifespan and have a significant impact on future social determinants as an adult, including food security status. Purpose: To explore the relationships between ACEs and food security among adults in the Appalachian counties of North Carolina and make comparisons with the rest of the state. Methods: Researchers used North Carolina's 2012 Behavioral Risk Factor Surveillance System data; namely, the ACEs optional module which includes 11 items related to experiences respondents had before the age of 18 and a single item from the Social Context optional module to classify food security status. The sample was divided into three age categories (18-44, 45-64, and 65 and older) for statistical comparisons as well as by the indicator for Appalachian county. Using Stata 15, weighted logistic regression was utilized for examining relationships between variables. Results: ACEs were a statistically significant predictor of food insecurity across all respondents; each additional ACE was associated with a 13-21% increase in the odds of food insecurity, depending on age group. However, living in an Appalachian county was only a predictor for those age 45-64. Implications: These findings highlight the long-term effects of childhood experiences on food security generally, and in Appalachia particularly for middle-aged adults. Reducing ACEs could reduce food insecurity and improve health in the region.