An epidemiological examination of neonatal opioid withdrawal syndrome and maternal and infant characteristics.

PURPOSE: Analyze maternal and infant characteristics by Neonatal Opioid Withdrawal Syndrome (NOWS) status and examine the association between mothers with Hepatitis C Virus (HCV) and infants diagnosed with NOWS. METHODS: Hospital discharge diagnoses of low-income women in Tennessee were used to identify NOWS cases (n = 1,369) in 2013 and 2014 and randomly selected controls (n = 1,369) were matched on county of residence and birth year. Maternal and infant characteristics were obtained by linking these data to birth certificate data. RESULTS: Of Tennessee's 683 cases of NOWS in 2013 and 686 in 2014, most (69%) occurred in Eastern Tennessee. Mothers of infants with NOWS were more likely to be older, unmarried, and white than mothers of infants without NOWS. Mothers of infants with NOWS also faced greater health risk: more smoking, HCV, herpes simplex diagnosis, and no or less frequent prenatal care (p < .0001). Infants with NOWS were more likely to present with infection, be admitted into the NICU, have lower birth weight, be enrolled in TennCare, but less likely to be breastfed than infants without NOWS (p < .0001). After adjusting for demographic factors and smoking, compared to mothers of infants without NOWS, mothers of infants with NOWS had an alarmingly increased odds of HCV [OR = 12.97 (95% CI 7.42, 22.66)]. CONCLUSIONS: This study emphasizes the complexity of challenges facing families impacted by NOWS, the importance of multifaceted prevention, and the need to conduct HCV testing in NOWS infants.

Beating trauma: Physical activity to promote resilience against substance use.

BACKGROUND: The relationship between adverse childhood experiences (ACEs) and frequent substance use (SU) is not well understood, impeding prevention efforts. METHODS: We assessed the relationship between ACEs and frequent SU and investigated if different modalities of physical activity (PA) moderate this pathway. The analysis included persons enrolled in the National Longitudinal Study of Adolescent to Adult Health who responded to surveys at Waves I (11-20 years), III (18-27 years), and IV (24-33 years). The impacts of cumulative ACEs and PA modalities on daily cigarette smoking, daily cannabis use, and binge drinking ≥ 3 times a week in emerging and early adulthood were assessed through adjusted logistic regression models. RESULTS: Among the sample (N=9451), 29.3%, 12.5%, and 7.8% experienced 1, 2, or 3 or more ACEs, respectively. With exception to binge drinking, cumulative ACEs (3+) were strongly associated with daily cannabis use in Wave III (aOR: 2.5; 95% CI: 1.6-3.6) and Wave IV (aOR: 2.1; 95% CI:1.3-3.3) and daily cigarette smoking in Wave III (aOR: 2.4; 95% CI: 1.9-3.0) and Wave IV (aOR: 2.3; 95% CI: 1.8-2.8). No PA modality moderated the ACEs to SU pathway; however, walking for exercise lowered the odds of current and prospective daily cannabis and cigarette use by 20-40%. Strength training, team sports, and individual sport participation were associated with 20-30% reduced risks of future daily cigarette use. CONCLUSION: The impacts of ACEs exposure on frequent SU persist into emerging and early adulthood. Future research should investigate the potential of PA to improve SU prevention strategies.

California's Comprehensive Perinatal Services Program and birth outcomes.

Introduction: California's Medicaid (Medi-Cal) sponsors Comprehensive Perinatal Services Program (CPSP), a program with enhanced perinatal care for women (more education, nutritional supplements, and psychosocial counseling/support). Past evaluations of CPSP's effectiveness in birth outcomes were limited to pilot programs and yielded mixed results. Methods: We used 2012-2016 California's statewide data about singleton live births with any receipt of prenatal care (N = 2,385,811) to examine whether Medi-Cal with CPSP enrollment was associated with lower odds of preterm birth (PTB), spontaneous PTB, and low birthweight (LBW) than non-CPSP births. With three binary variables of PTB, spontaneous PTB, and LBW as the response variables, three multilevel logistic models were used to compare the outcomes of participants enrolled in Medi-Cal with CPSP against those with private insurance, adjusting for maternal factors and county-level covariates. Results: Logistic models showed that participants enrolled to Medi-Cal with CPSP [n (%) = 89,009 (3.7)] had lower odds of PTB, spontaneous PTB and LBW, respectively, as compared with those with private insurance [n (%) = 1,133,140 (47.2)]. Within the Medi-Cal sub-population, the CPSP enrollment was associated with lower odds of PTB, SPTB and LBW than Medicaid beneficiaries without CPSP [n (%) = 967,094 (40.3)]. Discussion: With statewide data, these findings revealed a robust link between CPSP enrollment and better birth outcomes. Expanding access to comprehensive prenatal services could be an important strategy to improve birth outcomes.

Community Strengths and Challenges Related to Opioid Use Disorder in Rural Counties of East Tennessee.

Introduction: Appalachia, particularly Rural East Tennessee, has been and continues to be disproportionately impacted by opioid use disorder and its many tragic ramifications. Purpose: Community-engaged strategies can inform and support the development of relevant prevention efforts. Hence, people connected to a ten-county rural Appalachian region in East Tennessee were asked to identify and prioritize strengths and challenges related to opioid use disorder (OUD). Methods: Adult community members (n=577) completed a brief survey administered across 11 days in 2019. Results: Of the respondents, 85.3% never had been addicted to opioids, but 74.0% had someone close to them with OUD. The most frequently selected community strength was support for people with OUD to seek help and the most frequently selected challenge was lack of treatment and recovery services. People with personal OUD experience reported significantly higher mean levels of OUD-related stigma compared to persons without such experience. Implications: The number of respondents indicates a local concern and commitment related to OUD in rural Appalachia. The findings prioritized areas of focus-both in needs to be addressed and strengths on which to capitalize. These community insights will guide the selection and development of OUD-related overdose prevention for this region.

Experiences of United States Graduates at the Latin American Medical School in Cuba: A Road Less Traveled.

OBJECTIVES: Determine if United States graduates of the Latin American Medical School in Cuba: 1) provide primary health care to disadvantaged populations; 2) complete licensing exams and obtain residencies; and 3) accrue additional debt during their medical education. METHODS: A Qualtrics secure web-based survey was provided to 158 graduates via email, completed anonymously. Responses were compiled and descriptive statistics generated. RESULTS: Fifty-six valid surveys were returned, for a response rate of 35.4%. Chi-square analysis showed no statistically significant differences between survey respondents and the sampling frame. Most graduates are people of color; 68% work in clinical medicine; of these, 90% are in primary care, with 100% serving disadvantaged populations. Most accrued no further educational loan debt. CONCLUSIONS: United States graduates of the Latin American Medical School work in primary care with disadvantaged populations. Graduates accrue little additional student loan debt.

Barriers to recruitment and retention of undergraduate men as college sexual assault prevention peer educators.

Objective: Male allies play an important role in sexual assault prevention, yet many college sexual assault prevention programs struggle to recruit and retain men. This study aims to identify barriers to recruitment and retention of male sexual assault prevention peer educators. Participants: Seventeen undergraduate male student leaders participated in this study during summer 2018. Methods: Semi-structured phone interviews were conducted, recorded, and transcribed. Response data were thematically analyzed. Results: Barriers to recruitment include perceived gender norms and discomfort with the topic of sexual assault. Barriers to retention include male peer educators' perception that women are resistant to men discussing sexual assault. Suggestions for improving recruitment and retention efforts are also identified. Conclusions: Recruitment and retention of male sexual assault prevention peer educators may require recruitment approaches that are tailored to men and programmatic changes that position men as allies in sexual assault prevention.

Prenatal Opioid Exposure and ADHD Childhood Symptoms: A Meta-Analysis.

To systematically investigate the association between prenatal opioid exposure (POE) and attention-deficit hyperactivity disorder (ADHD) symptoms in children 2-18 years old, studies were searched using PubMed, CINAHL, PsycINFO, and Web of Science from January of 1950 to October of 2019. Inclusion criteria were observational studies reporting ADHD symptoms of children with POE compared with non-exposed children or normative data. The study protocol was registered with PROSPERO: CRD42018115967. Two independent reviewers extracted data on hyperactivity/impulsivity, inattention symptoms, ADHD combined subscale symptoms, and sample characteristics. Of 223 articles screened, seven met the inclusion criteria. Data represent 319 children with POE and 1308 non-exposed children from 4.3 to 11.2 mean years from five countries. POE was positively associated with childhood hyperactivity/impulsivity (d = 1.40; 95% CI, 0.49-2.31; p = 0.003), inattention (d = 1.35; 95% CI, 0.69-2.01; p < 0.0001), and combined ADHD symptoms scores (d = 1.27; 95% CI = 0.79-1.75; p < 0.0001). POE was positively associated with ADHD combined symptom scores at preschool (d = 0.83, 95% CI, 0.57, 1.09; p < 0.0001) and school age (d = 1.45, 95% CI, 0.85 to 2.04; p < 0.0001). Results suggest increased risk of ADHD symptoms during school age. Future research is needed to clarify the relationship between biological, social, and environmental risk and ADHD symptoms for children who experienced POE.

Treating infants with neonatal abstinence syndrome: an examination of three protocols.

OBJECTIVE: Describe the characteristics of infants with NAS and determine if treatment outcomes varied between three protocols. STUDY DESIGN: Based on medical record data, infant treatment for NAS-related withdrawal reflected one of three protocols: (1) No rescue dose (n = 836, 52.7%): Prescriber ordered initiation and escalation doses and determined when infants were eligible for weaning, (2) Rescue dose (n = 233, 14.7%): No rescue dose with the addition of a prescriber-ordered rescue dose, (3) Rescue dose by order set (n = 516, 32.6%): Rescue dose with addition of nurse-assisted order of morphine during escalation. RESULTS: The no rescue dose group had longer length of stay, days to wean, and inpatient days, and greater initial morphine dose than the two rescue dose groups (p < 0.001). Treatment outcomes between the two rescue dose protocols did not differ. CONCLUSIONS: The benefits related to rescue dosing further inform the development of a standardized NAS treatment protocol.

Reproductive Health Knowledge, Attitudes, and Behaviors Among Women Enrolled in Medication-Assisted Treatment for Opioid Use Disorder.

BACKGROUND: The lifetime prevalence of unintentional pregnancy among women enrolled in medically assisted treatment (MAT) for opioid use disorder (OUD) has been reported to exceed 80%. Consistent voluntary contraception use by women enrolled in MAT programs can reduce their risk of unintended pregnancies and increase their opportunity to plan the family size they want, yet little is understood about past and current contraception use or associated barriers and facilitators for this population of women. MATERIALS AND METHODS: Women enrolled in treatment for OUD at two MAT clinics in East Tennessee were invited to participate in an anonymous survey about contraception. We describe the sociodemographic and health characteristics of the women (N = 287; estimated response rate of 81.0%), report on their contraception knowledge and attitudes, and assess how these characteristics are associated with current contraception use. RESULTS: Most of the 287 women had been sexually active in the past 12 months (88%), were pregnant at least once (98%), and were insured (58%). Women having undergone bilateral tubal ligation had a greater average number of pregnancies (including those while on birth control), lower mean levels of depressed mood, and higher mean level of agreement that avoiding pregnancy now was important and that pregnant women should not use painkillers, compared to the women not using contraception. CONCLUSIONS: Strategies to ensure all women enrolled in MAT for OUD have knowledge of effective contraception and affordable, quality contraception care that is responsive to their complicated and oftentimes traumatic histories are necessary to enhance the women's reproductive health.

Neonatal Abstinence Syndrome in East Tennessee: Characteristics and Risk Factors among Mothers and Infants in One Area of Appalachia.

OBJECTIVE: To describe the epidemiology of neonatal abstinence syndrome (NAS) in a 16-county Appalachian area of eastern Tennessee. METHODS: The Tennessee Surveillance System for NAS provided data on maternal sources of opioids. Data linking hospital discharge diagnosis for NAS to birth certificate data allowed us to compare maternal, delivery, and infant characteristics for NAS births with those for non-NAS births. RESULTS: There were 339 cases of NAS in 2013 and 367 in 2014, for NAS rates of 25.5 and 28.5 per 1,000 live births, respectively. When compared with the state overall, mothers of NAS infants in eastern Tennessee were more likely to use opioids that had been prescribed to another person. There were numerous maternal, infant, and delivery characteristics that were significantly different for NAS births compared with non-NAS births. CONCLUSION: Neonatal abstinence syndrome is epidemic in the eastern Tennessee area of Appalachia, with unique maternal and infant characteristics that have important implications for primary, secondary, and tertiary prevention.

A Population Health Driver Diagram to Address Neonatal Abstinence Syndrome.

This article describes the process for developing a population health driver diagram to address a priority health issue in East Tennessee: neonatal abstinence syndrome (NAS). Population health driver diagrams are used in quality improvement processes for determining and aligning actions that a community can take to achieve a specified outcome. The Tennessee Department of Health contracted with the University of Tennessee's Department of Public Health to conduct a community participatory process to contribute to a statewide health improvement plan. Colleagues in local public health practice identified NAS as the leading perinatal health issue, and community engagement was achieved by involving community health councils. Qualitative and quantitative data were collected, analyzed, and provided to these councils. A region-wide stakeholders' meeting resulted in the development of a population health driver diagram to address NAS. We describe this process and provide lessons learned that can be valuable in other settings. Population health diagrams have important implications for practice because of their use as a framework for community action, especially in the context of a community health assessment.

How Schools Can Promote Healthy Development for Newly Arrived Immigrant and Refugee Adolescents: Research Priorities.

BACKGROUND: The US education system must find creative and effective ways to foster the healthy development of the approximately 2 million newly arrived immigrant and refugee adolescents, many of whom contend with language barriers, limited prior education, trauma, and discrimination. We identify research priorities for promoting the school success of these youth. METHODS: The study used the 4-phase priority-setting method of the Child Health and Nutrition Research Initiative. In the final stage, 132 researchers, service providers, educators, and policymakers based in the United States were asked to rate the importance of 36 research options. RESULTS: The highest priority research options (range 1 to 5) were: evaluating newcomer programs (mean = 4.44, SD = 0.55), identifying how family and community stressors affect newly arrived immigrant and refugee adolescents' functioning in school (mean = 4.40, SD = 0.56), identifying teachers' major stressors in working with this population (mean = 4.36, SD = 0.72), and identifying how to engage immigrant and refugee families in their children's education (mean = 4.35, SD = 0.62). CONCLUSION: These research priorities emphasize the generation of practical knowledge that could translate to immediate, tangible benefits for schools. Funders, schools, and researchers can use these research priorities to guide research for the highest benefit of schools and the newly arrived immigrant and refugee adolescents they serve.

Obstacles to parent-adolescent communication in Hmong American families: exploring pathways to adolescent mental health promotion.

OBJECTIVE: Mental health challenges disproportionately affect children in refugee families, with Hmong American adolescents being an extreme case (Thao, Leite, and Atella 2010). Limited understanding about the processes associated with this enhanced risk for children of refugees exists. Obstacles to parent-adolescent communication may contribute to this increased risk (Laursen and Collins 2004). This study's objective is to explore our limited understanding of parent-adolescent communication in refugee families by examining communication obstacles among Hmong Americans. DESIGN: Thirty Hmong American young adults (18 to 25 years; mean = 21.2, 50% female or n =15) participated in interviews that focused retrospectively on the parent-adolescent relationship. RESULTS: Results revealed obstacles that were initiated by the adolescent, parent, and community. Two adolescent-focused sub-themes (emotional discomfort and psychosocial immaturity), five parent-focused sub-themes (parental judgment, parental intimidation, no benefits of communication with parents, generational/cultural differences, and lack of parent-adolescent bond), and two culture/community-focused sub-themes (traditions/values and vocabulary) emerged. CONCLUSIONS: The findings provide a foundation for future qualitative and quantitative studies to promote Hmong American family communication, and encourage an ecological approach to promote parent-adolescent communication conducive to supporting adolescent mental health outcomes.

Older not wiser: risk of prenatal alcohol use by maternal age.

High levels of alcohol use among pregnant women have been associated with a spectrum of birth defects. Greater maternal age has been related to an increased risk of drinking during pregnancy. Although the context, process, and outcomes of pregnancy and alcohol use vary by maternal age, no studies have examined predictors of prenatal drinking by age. This study addresses this gap by examining potential risk factors associated with prenatal alcohol use (any versus none) by maternal age (<20, 20-25, 26-34, and 35 years or older). Descriptive and logistic regression analyses were completed on survey data from 9,004 pregnant women from the north central U.S. Descriptive statistics revealed teens in general had a higher level or greater occurrence of risk factors previously identified with prenatal drinking compared to older women, yet women of advanced maternal age (35 years or older) were most likely to drink alcohol during pregnancy. Based on the regression by age, 20-25 year old women had the greatest number of significant risk factors associated with prenatal drinking including being employed, white, unmarried, first birth, smoking prenatally, greater levels of depressed mood, and more experiences related to alcohol abuse. The number and patterns of significant predictors of drinking alcohol while pregnant by age encourage greater investigation of other social, contextual factors that might contribute to the risk of prenatal drinking. This is especially salient for women of advanced maternal age, for whom very few significant predictors emerged.

'Don't cross a man's feet': Hmong parent-daughter communication about sexual health.

Parent-adolescent communication about sexual health is one strategy to encourage healthy adolescent sexual behaviour. However, this literature has largely overlooked immigrant families. Hmong youth, identified as facing extreme challenges to parent-adolescent communication, are considered. Content analysis was used to examine parent-adolescent communication about sexual health for forty-four pregnant or parenting Hmong adolescent girls. The minority of adolescents recalled an actual conversation about sexual health in their families with mothers most often identified as the source. Their stories reflect discussions about abstinence, puberty, pregnancy, and STIs - with much information being inaccurate. With culture being a recurrent theme, communication was reported to be hindered by cultural traditions, comfort level, applicability, and perceived consequences. The results identify opportunities for culturally-relevant sex education materials in the Hmong community.

Correlates of prenatal alcohol use.

OBJECTIVE: S: To identify correlates of prenatal alcohol use in a statewide population-based sample. METHODS: A self-reported survey was conducted in 67 prenatal clinics in Minnesota with 4,272 women at their first prenatal visit. Chi-squared and multivariate logistic regression analyses were conducted to identify risk markers associated with any prenatal alcohol use. RESULTS: Nearly 27% of the respondents were calculated as having used alcohol during pregnancy. In multivariable analyses, the following were risk markers for prenatal alcohol use: older age, being unmarried, lower gravidity, greater depressed mood, currently smoking, exposure to intrapersonal violence, a history of not remembering things because of alcohol use, and feelings that the respondent should reduce her drinking. Subsequent analyses revealed that the association of intrapersonal violence with prenatal drinking was mediated by whether the woman reported that she did not remember things while drinking or that the woman felt she should reduce her drinking. CONCLUSIONS: The demographic and behavioral correlates reported here are consistent with previous research. The significance of two alcohol behavioral factors (i.e., not remembering things and feeling that she should reduce her drinking) suggest that the women who drank during pregnancy would likely have substance abuse issues.

Assessing the risk of fetal alcohol syndrome: understanding substance use among pregnant women.

Fetal alcohol exposure is a common cause of birth defects and developmental disorders. As many as 1 in 100 children in the United States are believed to be affected by fetal alcohol exposure. Characteristics of fetal alcohol syndrome (FAS) include abnormal facial features, growth impairment, problems with learning, memory, attention span, problem solving, speech, and hearing. FAS is 100% preventable. Preliminary data from 1704 pregnant women in Minnesota were assessed: substance use during pregnancy, risk factors related to substance use during pregnancy, and how substance use among pregnant women varies across the state. Of the sample, 19.6% of the women were calculated to have drunk alcohol while pregnant. Nondrinkers were more likely to be married and unemployed than drinkers. The drinkers reported significantly higher levels of depressed mood and greater number of problems with alcohol than their abstaining counterparts. Abstainers reported a greater number of pregnancies and initiated their first prenatal visit earlier than the drinkers. Significant differences in prenatal substance use and related factors also emerged by geographic region in Minnesota. Findings are discussed in relation to prevention and policy efforts.

Adolescent sexuality and parent-adolescent processes: promoting healthy teen choices.

Trends in adolescent sexual health, the relation between parenting and adolescent sexual outcomes, and adolescent sexuality interventions with a parent component are reviewed. American adolescents have higher rates of unprotected sex and sexually transmitted infections contraction than adults and nine times the teen pregnancy rate of their European counterparts. Parenting efforts are related to adolescent sexual behavior. The review of 19 relevant programs supports the incorporation of theory and the ecological model in program design and evaluation.