Contraceptive care service provision via telehealth early in the COVID-19 pandemic at rural and urban federally qualified health centers in 2 southeastern states.

PURPOSE: To investigate telehealth use for contraceptive service provision among rural and urban federally qualified health centers (FQHCs) in Alabama (AL) and South Carolina (SC) during the initial months of the COVID-19 pandemic. METHODS: This is a mixed-methods study using data from the FQHC Contraceptive Care Survey and key informant interviews with FQHC staff in AL and SC conducted in 2020. Differences between rural and urban clinics in telehealth use for contraceptive service provision were assessed with a chi-square test of independence. Interviews were audio recorded, transcribed, and coded to identify facilitators and barriers to telehealth. FINDINGS: Telehealth for contraceptive care increased during the early months of the pandemic relative to prepandemic. Fewer rural clinics than urban clinics provided telehealth for contraceptive counseling (16.3% vs 50.6%) (P = .0002), emergency contraception (0.0% vs 16.1%) (P = .004), and sexually transmitted infection care (16.3% vs 34.6%) (P = .031). Key facilitators of telehealth were reimbursement policy, electronic infrastructure and technology, and funding for technology. Barriers included challenges with funding for telehealth, limited electronic infrastructure, and reduced staffing capacity. CONCLUSIONS: Differences in telehealth service provision for contraceptive care between rural and urban FQHCs highlight the need for supportive strategies to increase access to care for low-income rural populations, particularly in AL and SC. It is essential for public and private entities to support the implementation and continuation of telehealth among rural clinics, particularly, investing in widespread and clinic-level electronic infrastructure and technology for telehealth, such as broadband and electronic health record systems compatible with telehealth technology.

Telehealth for Contraceptive Care During the Initial Months of the COVID-19 Pandemic at Local Health Departments in 2 US States: A Mixed-Methods Approach.

OBJECTIVES: This study examined implementation of telehealth for contraceptive care among health departments (HDs) in 2 Southern US states with centralized/largely centralized governance structures during the early phase of the COVID-19 pandemic. Sustaining access to contraceptive care for underserved communities during public health emergencies is critical. Identifying facilitators and barriers to adaptive service provision helps inform state-level decision making and has implications for public health policy and practice, particularly in states with centralized HD governance. DESIGN: Mixed-methods study including a survey of HD clinic administrators and key informant interviews with clinic- and system-level staff in 2 states conducted in 2020. SETTING: Health department clinics in 2 Southern US states. PARTICIPANTS: Clinic administrators (survey) and clinic- and system-level respondents (key informant interviews). Participation in the research was voluntary and de-identified. MAIN OUTCOME MEASURES: (1) Telehealth implementation for contraceptive care assessed by survey and measured by the percentage of clinics reporting telehealth service provision during the pandemic; and (2) facilitators and barriers to telehealth implementation for contraceptive care assessed by key informant interviews. For survey data, bivariate differences between the states in telehealth implementation for contraceptive care were assessed using χ2 and Fisher exact tests. Interview transcripts were coded, with emphasis on interrater reliability and consensus coding, and analyzed for emerging themes. RESULTS: A majority of HD clinics in both states (60% in state 1 and 81% in state 2) reported a decrease in contraceptive care patient volume during March-June 2020 compared with the average volume in 2019. More HD clinics in state 1 than in state 2 implemented telehealth for contraceptive services, including contraceptive counseling, initial and refill hormonal contraception, emergency contraception and sexually transmitted infection care, and reported facilitators of telehealth. Medicaid reimbursement was a predominant facilitator of telehealth, whereas lack of implementation policies and procedures and reduced staffing capacity were predominant barriers. Electronic infrastructure and technology also played a role. CONCLUSIONS: Implementation of telehealth for contraceptive services varied between state HD agencies in the early phase of the pandemic. Medicaid reimbursement policy and directives from HD agency leadership are key to telehealth service provision among HDs in centralized states.

From training to implementation: Improving contraceptive practices in South Carolina.

OBJECTIVE: Capacity building and training to improve contraceptive care is essential for patient-centered care and reproductive autonomy. This study assessed the feasibility of translating the knowledge and skills gained from contraception trainings into improvements in practice. STUDY DESIGN: Participants completed surveys following contraceptive care trainings provided to family planning clinic and hospital obstetric providers and staff as a part of the Choose Well contraceptive access initiative in South Carolina. Surveys assessed participants' intent to change their practice post-training and anticipated barriers to implementing change. A mixed-methods approach was utilized including descriptive analysis of Likert scale responses and thematic content analysis to synthesize open-ended, qualitative responses. RESULTS: Data were collected from 160 contraceptive training sessions provided to 4814 clinical and administrative staff between 2017 and 2019. Post-training surveys were completed by 3464 participants (72%), and of these, 2978 answered questions related to the study outcomes. Most respondents (n = 2390; 80.7%) indicated intent to change their practice and 35.5% (n = 1044) anticipated barriers to implementing intended changes. Across all training categories, organizational factors (time constraints, policies and practices, infrastructure/resources) were the most frequently perceived barrier to improving contraceptive services. Structural factors related to cost for patients were also identified as barriers to IUD and implant provision. CONCLUSION: The trainings were successful in influencing family planning staff and providers' intent to improve their contraceptive practices, yet some anticipated barriers in translating training into practice. Improvements in organizational and structural policies are critical to realizing the benefits of trainings in advancing quality contraceptive care. IMPLICATIONS: In addition to training, coordinated efforts to address organizational practices and resources, coupled with system-level policy changes are essential to facilitate the delivery and sustainability of patient-centered contraceptive care.

Contraceptive Access at Federally Qualified Health Centers During the South Carolina Choose Well Initiative: A Qualitative Analysis of Staff Perceptions and Experiences.

Introduction: Federally qualified health centers (FQHCs) provide essential contraceptive services to low-income individuals; yet, access to all method options, notably intrauterine devices (IUDs) and implants, may be limited at non-Title X FQHCs. The South Carolina (SC) Choose Well initiative is a statewide contraceptive access initiative that was launched in 2017 and extends into 2022. Choose Well established a collaborative network between training and clinical partners and is aimed at facilitating implementation of contraceptive care best practices through capacity-building and training of clinical and administrative staff in partner organizations. The initiative provided funding for workforce expansion and contraceptive methods. We examined perceptions of staff from Choose Well-participating FQHCs regarding contraceptive access during the first 2 years of the initiative, including factors that facilitated or posed access challenges as well as sustaining factors. This study informs the process evaluation of Choose Well while providing data critical for uncovering and scaling up contraceptive access initiatives. Materials and Methods: Interviews were conducted with FQHC staff (n = 34) in 2018 and 2019 to assess Choose Well implementation and were recorded, transcribed, and double-coded via at least 80% interrater reliability or consensus coding. Data were analyzed according to clinical and administrative factors influencing contraceptive access. Results: Increased capacity for contraceptive counseling and provision through training and external funding for IUDs and implants were the most noted clinical factors facilitating access. Streamlining workflow processes was also a facilitator. Buy-in and engagement among staff and leadership emerged as a facilitator at some clinics and as a barrier at others. Policy/structural factors related to costs of devices and insurance coverage were identified as threats to sustainability. Conclusions: The Choose Well initiative contributed to the perception of an increase in contraceptive access at participating FQHCs in SC. Statewide contraceptive access initiatives have the potential to support FQHCs in meeting their clients' contraceptive needs. Organizational buy-in, sustainability of funding, and training are key to realizing the full potential of these initiatives.

Social Support for Physical Activity for High Schoolers in Rural Southern Appalachia.

OBJECTIVE: Social support for physical activity (PA) has been shown to enhance PA levels in adolescents. Although social support has been examined extensively in the literature, less is known about the role of social support for PA for high school adolescents in rural southern Appalachia. PA is important because adolescent obesity is greater in Appalachia than in the rest of the United States. METHODS: This was a qualitative secondary analysis of focus groups conducted in 2013-2014 among parents, teachers, and high school students (N = 77) in 6 counties across rural southern Appalachia. Beets' typology of social support was used to categorize themes. RESULTS: Participants discussed instrumental supports, including providing transportation and paying fees, enrolling child in recreation/sports, and providing PA equipment at home. Performing PA with adolescents and modeling, watching/supervising, and prioritizing PA were identified as conditional supports. Several motivational supports were identified: encouragement, force, and the admiration of people who are active. Participants also identified key informational supports, including discussing the importance/health benefits of PA, how to be physically active, and general advice/information. Barriers to PA engagement (eg, body image issues, bullying, competitive nature of PA opportunities) and the role of referent groups (eg, family, peers, teachers) emerged as important concepts in the discussion. CONCLUSION: This study identifies opportunities and practical ways for families and schools to provide, build, and strengthen supports for PA among adolescents in rural Appalachia.

Bone Accrual in Children and Adolescent Nonelite Swimmers: A 2-Year Longitudinal Study.

OBJECTIVE: To examine differences in bone mass between children and adolescents swimming competitively at nonelite levels (locally and regionally) and nonathletes and to assess changes in bone mass in these 2 groups over 24 months after taking into consideration several known confounders of bone mass. DESIGN: Observational prospective study. PARTICIPANTS: White nonelite swimmers (n = 128) and nonathletes (n = 106) 8 to 18 years of age from Memphis, Tennessee, USA. MAIN OUTCOME MEASURES: Participants underwent dual-energy x-ray absorptiometry to assess total body and hip bone mineral content (BMC) at baseline and 12 and 24 months later. RESULTS: At baseline, swimmers had 4.2% and 6.1% higher adjusted BMC for the total body and hip, respectively, compared with nonathletes (P values < 0.027). Averaging across assessment points, swimmers had 73.5 and 2.2 g higher BMC for the total body and hip, respectively, than nonathletes. Although there was a significant annual increase in total body and hip BMC in both groups (33.5 and 0.7 g, respectively), there was no difference in annualized bone accrual between swimmers and nonathletes for either total body BMC (swim by time effect; P = 0.213) or hip BMC (P = 0.265). CONCLUSIONS: Competitive swimming at nonelite levels during childhood and adolescence does not seem to compromise bone accrual.

Barriers to Healthy Eating Among High School Youth in Rural Southern Appalachia.

Introduction: Diet and nutrition play an important role in a child's health and reduce the risk of numerous health problems including obesity. Dietary habits can be difficult to modify in children, particularly in Appalachia, where access to affordable, healthy foods is limited. Purpose: To examine barriers to healthy eating among Appalachian youth. Methods: In 2013-2014, data were gathered via focus groups and interviews from parents, school personnel, and adolescents (N=99) in six counties across southern Appalachia. Data were analyzed using thematic network analysis. Analysis was completed in 2015. Results: Participants identified multiple barriers to healthy eating among adolescents. Barriers comprised three global themes: cultural norms, school-based nutrition policy and programming, and rurality. Within the individual and home environment, beliefs and practices, time management, and preference for unhealthy foods affected adolescents' dietary behaviors. Schools faced challenges in terms of translating nutrition policy into practice, providing nutrition education, and engaging stakeholders. Limited socioeconomics and food deserts/swamps were community-level impacts. Implications: Participants discussed how adolescents' eating behaviors were shaped by social, physical, and environmental factors (e.g., cultural norms, school-based nutrition policy/programming, and rurality). These findings provide important insights into barriers to healthy eating in this population and point to future directions for research and practice. For example, the findings can be used by school personnel to develop ecologic approaches to school-based nutrition programming in Appalachia. Student associations can also use these findings to actively participate in efforts to improve school food offerings.

The influence of maternal body mass index and physical activity on select cardiovascular risk factors of preadolescent Hispanic children.

BACKGROUND: Maternal obesity and physical inactivity have been identified as correlates of overweight and obesity and physical inactivity in older preadolescents; however, no study has explored this relationship in Hispanic preadolescents. Furthermore, the relation between maternal physical activity (PA) and blood pressure (BP) in Hispanic preadolescents has not been examined. PURPOSE: This study aimed to assess the associations between Hispanic mothers' PA and body mass index (BMI) and their preadolescents' PA, screen time, BP, and BMI. METHODS: Data of 118 mother-child (aged 2-10 years) dyads enrolled in a cross-sectional study of metabolic syndrome in Hispanic preadolescents at a community health center in Johnson City, TN were used. Parent and child questionnaires were used to ascertain mothers' BMI and PA and preadolescents' PA and screen time. Preadolescents' height, weight, and BP were measured. Multiple logistic regression was used to examine the association between child and maternal variables, adjusting for mother's education and the child's sex and age. RESULTS: Pradolescents of obese mothers were more likely than preadolescents of mothers with normal weight to engage in less than three days of at least 60 min of vigorous PA per week (OR: 6.47, 95% CI [1.61-26.0]). Preadolescents whose mothers did not engage in moderate PA were more likely to engage in less than three days of at least 60 min of vigorous PA per week (OR: 2.92, CI [1.18-7.24]); and have elevated BP (OR: 2.50, 95% CI [1.02-4.53]) than preadolescents whose mothers engaged in moderate PA. DISCUSSION: Our results show a negative relationship between maternal obesity and preadolescent PA, and a positive relationship between lower maternal PA and elevated BP and lower PA in Hispanic preadolescents. This suggests that interventions aimed at improving Hispanic preadolescents' PA and BP may use maternal PA and maternal BMI (for preadolescent PA) as a modification strategy to improve health in Hispanic preadolescents.

Weight Misperception and Health-Related Quality of Life in Appalachian Adolescents in the United States.

Introduction There is limited research on the relation between weight misperceptions and health-related quality of life (HRQoL) among U.S. adolescents. Methods Baseline data (n = 1509) collected in 2012 from the Team Up for Healthy Living project were used. Measures included BMI percentiles calculated from measured height and weight; self-perception of weight status; and the 23-item PedsQL™ Inventory. Multiple linear regression was performed after adjustment for covariates to examine associations between weight misperception and HRQoL. Results Compared to accurate weight perception, weight underestimation was associated with higher total HRQoL (ß = 2.41), physical health (ß = 2.77), and emotional (ß = 2.83), social (ß = 2.47) and psychosocial functioning (ß = 2.38) (all p < 0.05). Weight overestimation was associated with lower social functioning (ß = -13.13, p < 0.05). Stratified by gender, associations were observed only in males. Discussion Weight underestimation had greater association with HRQoL than weight overestimation; and varied by gender. Better understanding of these associations will assist in improving the health of adolescents in Southern Appalachia.

Trait Hope and Preparation for Future Care Needs among Older Adult Primary Care Patients.

We examined associations between trait hope and preparation for future care needs (PFCN) among 66 older adult primary care patients in western New York. Participants completed a questionnaire assessing PFCN (awareness, information gathering, decision-making, concrete planning, and avoidance), and the Adult Trait Hope Scale. In multivariate regressions, lower hope, particularly less agency, was associated with more awareness of needing care, whereas higher hopefulness, particularly pathways thinking, was associated with increased decision-making and concrete planning. Greater hopefulness appears to be linked to goal-directed planning behaviors, although those with lower hope may actually be more aware of the need for planning. Evidence-based programming that encourages learned hopefulness may contribute to enhanced health planning and decision-making among older adult primary care patients.

Relationship Between Physical Activity and Suicidal Behaviors Among 65,182 Middle School Students.

BACKGROUND: The psychosocial benefits of participating in physical activity (PA) are well known; less is known about the relationship between suicidal behaviors and PA among adolescents, especially among middle school-aged youth. This study seeks to fill that gap by assessing the cross-sectional relationship between these variables. METHODS: A secondary analysis of the 2010 Tennessee Middle School Youth Risk Behavior Survey data was conducted among 65,182 middle school students. Items examined were PA, sports team engagement, physical education (PE) class, screen time, suicidal behaviors, drug/substance use, extreme weight control behaviors, weight status and weight misperceptions, and selected personal characteristics. Multiple logistic regression analysis was used to estimate the association between PA, sports team engagement, and PE class attendance on suicidal behaviors. RESULTS: Sports team engagement was significantly associated with suicidal thoughts, plans, and attempts even after controlling for other important variables. There was no relationship, however, between total PA or PE class attendance in univariate or multivariate models, respectively. CONCLUSIONS: Findings suggest that sports team engagement is associated with reduced risk for suicidal thoughts, plans, and attempts, whereas, no relationships were found for PA or PE class attendance. Asking adolescents questions about sports team engagement may help clinicians screen for risk of suicidal behaviors.

College students as facilitators in reducing adolescent obesity disparity in Southern Appalachia: Team Up for Healthy Living.

The proportion of obese adolescents in Southern Appalachia is among the highest in the nation. Through funding from the National Institute on Minority Health and Health Disparities--National Institutes of Health, the Team Up for Healthy Living project was a cluster-randomized trial targeting obesity prevention in adolescents through a cross-peer intervention. The specific aims of the project were to: 1) develop a peer-based health education program focusing on establishing positive peer norms towards healthy eating and physical activity (PA) among high school students, 2) test program efficacy, and 3) explore mechanisms underlying the program. The study was guided by the Theory of Planned Behavior, which presupposes that human behavior is primarily driven by attitude, subjective norms, perceived behavioral control, and social support. To deliver the intervention, undergraduate students from the disciplines of public health, nutrition, and kinesiology were hired as peer facilitators. Ten area high schools were invited to participate, were matched on demographics and then randomized to intervention or control. The primary outcomes of the study included body mass status, dietary behaviors, PA, and sedentary behaviors which were assessed at baseline and at three and twelve months post baseline. Intervention schools received Team Up for Healthy Living curriculum, which consists of eight 40-minute sessions. The curriculum focused on improving nutrition awareness, PA, leadership and communication. Control schools received their regularly scheduled Lifetime Wellness curriculum. The long-term goal of the study was to establish an effective academia-community partnership program to address adolescent obesity disparity in Southern Appalachia.

Examining General Versus Condition-Specific Health-Related Quality of Life Across Weight Categories in an Adolescent Sample.

This study examined health-related quality of life (HRQoL) across weight categories in adolescents using both a general and a condition-specific measure sensitive to fatigue symptoms. Participants (N = 918) completed the Pediatric Quality of Life (PedsQL) Inventory and PedsQL Multidimensional Fatigue Scale measures. Actual height and weight were used to calculate body mass index for age and sex percentiles and assign weight categories. No interaction effects between total HRQoL and weight category and gender were found; however, main effects were found for both weight category and gender. Future research should examine the impact of using different measures to assess HRQoL outcomes across weight categories.

School-based adolescent obesity prevention programming: perceptions of school personnel in Southern Appalachia.

OBJECTIVES: Coordinated School Health (CSH) is a systematic approach to improving the health and well-being of school-age children. It is recommended for its potential to promote healthy weight in adolescents through strategic programming. Resources and programming for adolescent obesity prevention varies among schools, thereby limiting the intended benefits of CSH. The purpose of this study was to understand gaps in schools' approaches to healthy weight promotion and support for overweight/obese students. We evaluated perceptions of adolescent obesity and environmental factors and programs facilitating healthy weight in high schools in Appalachian Tennessee. METHODS: In 2012, 17 key school personnel from 5 randomly selected high schools were interviewed. Questions addressed their perceptions of adolescent obesity, school-based physical activity and nutrition programming, and support available to overweight/obese students. Thematic analysis was conducted to identify emerging themes. RESULTS: Participants consistently identified adolescent obesity and/or associated risk factors as major health problems within their schools. Barriers to physical activity and healthful eating were identified at multiple levels. Because of the sensitivity surrounding overweight/obesity, no particular programs or curricula targeted overweight/obese adolescents specifically, but they were available to all students. Support is not explicitly available; therefore, overweight/obese students must seek out these resources. CONCLUSIONS: Findings suggest that although school personnel are concerned about the impact of adolescent obesity on health outcomes, there is wide variation across schools on the types and quality of programming available to address the issue. Results can be used to encourage school-based strengths and identify gaps in the CSH infrastructure in school systems.

Prevalence of and risk factors for adolescent obesity in Southern Appalachia, 2012.

The objective of this study was to examine weight status among southern Appalachian adolescents and to identify risk factors for obesity. We analyzed baseline data from the Team Up for Healthy Living study in 2012. Overall, 19.8% of the sample was overweight, and 26.6% was obese. Boys had higher rates of overweight/obesity than girls (50.5% vs 42.3%). Being male (odds ratio [OR] = 1.79; 95% confidence interval [CI], 1.39-2.29), having a mother with a high school education or less (OR = 1.39; 95% CI, 1.05-1.83), or having a father with a high school education or less (OR = 1.57; 95% CI, 1.17-2.09) was associated with a higher prevalence of obesity and a higher body mass index z score (ß = 0.131, 0.160, and 0.043, respectively, P < .05). Parental education could be used to identify adolescents with a higher likelihood of obesity.

Weight status misperception as related to selected health risk behaviors among middle school students.

BACKGROUND: Weight misperception has been documented among children although the impact on health risk behaviors is less understood, particularly among middle school students. The goals of this study were to describe sociodemographic differences in actual and perceived weight, correspondence between actual and perceived weight, and weight-related health risk behaviors, as well as to examine weight misperception and interactions with sociodemographic variables in explaining weight-related health risk behaviors. METHODS: Participants were recruited at 11 public school districts participating in the Tennessee Coordinated School Health (CSH) pilot program. A total of 10,273 middle school students completed the Centers for Disease Control and Prevention's Youth Risk Behavior Survey administered by teachers in the school setting. RESULTS: Findings revealed sociodemographic differences in actual and perceived weight as well as weight misperception. Although overestimating one's weight was significantly related to greater likelihood of weight-related health risk behaviors, significant interactions showed this relationship to be especially pronounced in females. Additional distinctions based on sociodemographic variables are indicated. CONCLUSIONS: Results highlight the importance of screening for health risk behaviors including weight misperception among middle school students. The CSH program offers an opportunity to understand health risk behaviors among students while also informing and evaluating methods for intervention.

Self-reported versus actual weight and height data contribute to different weight misperception classifications.

OBJECTIVES: The purpose of the study was to examine potential differences between two approaches to defining adolescent weight misperception. Specifically, weight status perception was compared with self-reported weight status and actual weight status (based on body mass index percentiles calculated from self-reported and actual weights and heights, respectively). Furthermore, the accuracy of assigning weight status based on body mass index percentiles calculated from self-reported weights and heights was assessed by comparing them with actual weight status. METHODS: Data were extracted from Team Up for Healthy Living, an 8-week, school-based obesity prevention program in southern Appalachia. Participants (N = 1509) were predominately white (93.4%) and ninth graders (89.5%), with approximately equivalent representation of both sexes (50.7% boys). RESULTS: The study revealed significant differences between the approaches to defining weight misperception (χ(2) = 16.2; P = 0.0003). CONCLUSIONS: Researchers should interpret study findings with awareness of potential differences based on the method of calculating weight misperception.

Reflections from an Undergraduate Student Peer Facilitator in the Team Up for Healthy Living School-Based Obesity Prevention Project.

Team Up for Healthy Living was a cluster-randomized trial to evaluate a cross-peer school-based obesity prevention program in Southern Appalachia. Undergraduate students from the disciplines of Kinesiology, Nutrition, and Public Health were trained as peer facilitators to deliver an 8-week curriculum in high school Lifetime Wellness classes. The focus of the curriculum was on improving diet and physical activity with an additional emphasis on enhancing leadership and communication skills. Control group participants received their regularly scheduled Lifetime Wellness curriculum. The current article is about the experiences of an undergraduate kinesiology student participating as a peer-facilitator in the Team-Up for Healthy Living trial. A brief overview of the program and peer facilitator training is followed by this students reflections on both personal development and student outcomes.