Community Legal Systems: Targeting PrEP and HIV Education to Decrease Risk of HIV Transmission.

The southern U.S. has both high HIV and incarceration rates in comparison to its population. As in the rest of the country, HIV prevention is based on education, behavior change, and biomedical efforts, such as pre-exposure prophylaxis (PrEP). This study examined the implementation of an educational intervention and supportive services to obtain PrEP in a population of individuals (N = 218) involved in an Adult Drug Court (ADC) or on probation or parole (P-P). Nearly all ADC and P-P participants self-reported risk behaviors linked to HIV acquisition. Results supported the acceptance and usefulness of the intervention as rated by participants. Participants showed increased knowledge of HIV risks and testing post-education. In multivariate analysis, predictors of interest in using PrEP included low stigma beliefs, specifically their level of prejudice views, high depressive symptoms, and white race. The intervention shows promise. Given the high risk documented for ADC and P-P individuals, HIV prevention is a critical component for increased protective behaviors.

Evaluation of Together We Inspire Smart Eating: pre-school fruit and vegetable consumption.

This study examined nutrition intervention curriculum, Together We Inspire Smart Eating (WISE). WISE is a research-based, nutrition promotion curriculum specifically designed for pre-school children from families with limited resources. The design was non-randomized treatment/control with standardized pre-/post-test assessments. Children (n = 268) in six Head Start centers received weekly food experiences from educators trained in WISE. Children (n = 258) in nine Head Start centers received weekly food experiences structured at the discretion of the educators untrained in WISE. Parents in both conditions (n = 268 WISE classroom, n = 258 comparison) were interviewed by educators twice over the school year using a data collection tool, The Family Map Inventory. Analyses using full information maximum likelihood controlling for pre-intervention consumption and key demographic characteristics was used to predict consumption at post-intervention assessment. Results indicated children in WISE centers consumed healthier food at home than children in non-WISE classrooms. The study suggested that WISE curriculum is an effective method to improve children's diets in at-risk environments.

Correction to: Keeping Our Eyes on the Prize: Focusing on Parenting Supports Depressed Parents' Involvement in Home Visiting Services.

The article "Keeping Our Eyes on the Prize: Focusing on Parenting Supports Depressed Parents' Involvement in Home Visiting Services", written by Lorraine M. McKelvey, Shalese Fitzgerald, Nicola A. Conners Edge and Leanne Whiteside­Mansell, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 28 May 2018 without open access.

Keeping Our Eyes on the Prize: Focusing on Parenting Supports Depressed Parents' Involvement in Home Visiting Services.

Objectives Improving family retention and engagement is crucial to the success of home visiting programs. Little is known about retaining and engaging depressed parents in services. The purpose of the study is to examine how home visit content moderates the association between depression and retention and engagement. Methods The sample (N = 1322) was served by Healthy Families America (n = 618) and Parents as Teachers (n = 704) between April 1, 2012 and June 30, 2016. Parents averaged 23 years (SD = 6). Nearly half of the parents were White (48%) and the majority was single (71%). Depression was screened with the Patient Health Questionnaire-2. Home visitors reported the percent of time focused on particular content and parent engagement at every home visit. Results Multilevel regression analyses showed the amount of time that home visitors spent supporting parent-child interaction moderated the association between depression and retention at 6 (B = .08, SE = .03, p = .003) and 12 (B = .1, SE = .03, p < .001) months, such that there was a stronger positive association for depressed parents. The main effects of child development focused content and retention at 6 (B = .07, SE = .01, p < .001) and 12 (B = .08, SE = .01, p < .001) months were positive, while effects of case management focused content at 6 (B = - .06, SE = .01, p < .001) and 12 (B = - .07, SE = .01, p < .001) months were negative. Conclusions Families were more likely to be retained when home visitors focused on child development and parent-child interaction, but less likely with more case management focus. Parents with positive depression screens were more likely to remain in services with more time spent focused on supporting parent-child interactions.

Table Talk: development of an observational tool to assess verbal feeding communications in early care and education settings.

OBJECTIVE: Children's dietary intake impacts weight status and a range of short- and long-term health outcomes. Accurate measurement of factors that influence children's diet is critical to the development and evaluation of interventions designed to improve children's diets. The purpose of the current paper is to present the development of the Table Talk observational tool to measure early care and education teachers' (ECET) verbal feeding communications. DESIGN: An observational tool to assess ECET verbal communication at mealtimes was deigned based on the extant literature. Trained observers conducted observations using the tool during lunch for both lead and assistant ECET. Descriptive statistics, test-retest for a subgroup, interclass correlations for each item, and comparisons between leads and assistants were conducted. SETTING: Head Start centres, Southern USA. SUBJECTS: Seventy-five Head Start educators. RESULTS: On average, 17·2 total verbal feeding communications (sd 8·9) were observed per ECET. For lead ECET, the most prevalent Supportive Comment was Exploring Foods whereas for assistants Making Positive Comments was the most prevalent. Overall, lead ECET enacted more Supportive Comments than assistant ECET (F(2,72)=4·8, P=0·03). The most common Unsupportive Comment was Pressuring to Eat, with a mean of 3·8 (sd 4·3) and a maximum of 25. There was no difference in Unsupportive Comments between lead and assistant ECET. CONCLUSIONS: Table Talk may be a useful tool to assess verbal feeding communications of ECET, with potential applications such as informing ECET training and assessing intervention efforts.

Assessment of Safe Sleep: Validation of the Parent Newborn Sleep Safety Survey.

PURPOSE: Sudden Infant Death Syndrome (SIDS) and suffocation account for more than half of all Sudden Unexpected Infant Deaths (SUID). The American Academy of Pediatrics (AAP) recommendations describe the safest environments to protect infants. This study compared parent responses on the Newborn Sleep Safety Survey and observational assessments (N=72) of infant sleep environments in families thought to be at high-risk for non-compliance with AAP recommendations. DESIGN AND METHODS: A naturalistic study of participants enrolled in two home visitation support programs was used. Observed risks ranged from 36.6% (never use pacifier) to 4.3% (never use firm mattress). RESULTS: Results comparing report to observation demonstrated acceptable concordance. Five items had fair concordance (Kappa>.4), four showed moderate concordance (Kappa>.6), and one excellent concordance (Kappa>.8). Although direct observation of safety behaviors is the gold standard in the injury prevention field, direct observation is logistically difficult, time consuming, and costly. CONCLUSIONS: Research and interventions aimed at a reduction of Sudden Infant Death Syndrome (SIDS) and suffocation require accurate assessment of the infant sleep environment. This study provides acceptable evidence for the use of the Newborn Sleep Safety Survey as an alternative to direct observation to assess parent adherence to recommendations. Limitations are discussed. PRACTICAL IMPLICATIONS: This study provided evidence of the usefulness of the Newborn Sleep Safety Survey, a parent survey of infant sleep environments. This tool will provide medical and research professionals a reliable, inexpensive tool to evaluation of the quality of sleep environments using a standard definition.

Low-Level Symptoms of Depression in Mothers of Young Children are Associated with Behavior Problems in Middle Childhood.

OBJECTIVES: Examine the association between mothers' low- and high-level depressive symptoms in early childhood and children's behavior problems in middle childhood. METHODS: We used data from 1844 families in a multi-site, longitudinal study beginning when children were 14 months and continuing to age 11 years. Children's internalizing and externalizing behavior problems at age 11 were assessed using the child behavior checklist for ages 6-18. Mothers' scores on the Center for Epidemiological Studies-Depression Scale when children were 14 months were used to classify them into three groups: 'no depressive symptoms', 'low-level depressive symptoms (below the clinical cut-off)' and 'clinically significant depressive symptoms (above the clinical cut-off).' RESULTS: Mothers were racially/ethnically diverse, including Caucasian (38.9 %), African-American (34.4 %), Hispanic (21.6 %), or other (5.1 %). More than one-third (39.2 %) were teenaged mothers, and 46.0 % did not complete high school. Of the 1844 families, 1172 had age 11 child outcome data. Logistic regression analyses controlling for family demographics revealed a significant association between early maternal depressive symptoms and later child behavioral outcomes. Both low level and clinically significant symptoms were associated with internalizing and externalizing behavior problems. For example, children whose mothers had low-level depressive symptoms were twice as likely to have clinically elevated internalizing problems compared with children whose mothers never had symptoms of depression. CONCLUSIONS: Children whose mothers experience low-level depressive symptoms early in their development have increased risk for later behavioral problems, suggesting a possible need for new screening and intervention strategies for mothers with lower than clinically elevated symptoms.

Grandmothers' Beliefs and Practices in Infant Safe Sleep.

Background Sudden infant death syndrome (SIDS) and suffocation are leading causes of infant mortality. Supine sleep position and use of appropriate sleep surfaces reduce SIDS risk but are not universally practiced. Mothers' decisions about sleep position and environment may be influenced by guidance provided by infants' grandmothers and other caregivers. Methods A survey was conducted of a convenience sample of grandmothers aged 30-70 years who provide care at least weekly for an infant grandchild <6 months old. The survey was distributed through community partners of a university-based research team. Respondents received home safety items as compensation. Analyses focused on the relationship of grandmother demographic characteristics and beliefs on their reported practices related to infant sleep. Results Among the 239 grandmothers, 45 % reported placing infants to sleep supine on an appropriate sleep surface at the grandmother's house, while 58 % reported doing so when the infant was sleeping in the mother's house. After adjusting for other factors, respondents were less likely to adhere to recommended guidelines when they believed supine position increased choking risk (OR 0.34, 95 % CI 0.18-0.62) or believed infants are more comfortable or sleep longer when on their stomachs (OR 0.51, 95 % CI 0.28-0.93). Discussion Grandmothers do not universally observe evidence-based safe sleep practices, particularly if the infant is not sleeping in the home of the parent. Interventions for senior caregivers focused on perceived choking risk, infant comfort in the supine position, and other recent changes in recommended safety practices are warranted.

Child and family factors associated with teacher-reported behavior problems in young children of substance abusers.

BACKGROUND: We examined child and family factors associated with teacher-reported behavior problems in 79 children of substance abusers (COSAs). METHOD: Using regression models, we examined the impact of four family risk factors, cumulatively and individually, on children's behavior and explored children's engagement of adults as a protective factor. RESULTS: More than half (55%) of children had clinically elevated behavior problems. Cumulative family risks were associated with increased problems, whereas the presence of a father in the home and the child's ability to engage adults were protective. CONCLUSIONS: These findings may help explain the variation in behavioral outcomes of COSAs.

Risks of adverse childhood experiences on healthcare utilization and outcomes in early childhood.

BACKGROUND: The American Academy of Pediatrics recommends all pediatricians to be ready to implement trauma-informed care, including the mitigation of impacts of Adverse Childhood Experiences (ACEs) through screening and identification of at-risk population. Reliable survey tools and knowledge of the consequences of ACEs are needed. OBJECTIVE: This study examines the healthcare utilization and diagnoses captured in insurance claims in association with the number of ACEs recorded by the Family Map Inventories (FMI). The FMI offers a comprehensive family assessment, which includes child ACEs (FMI-ACEs) using prospective, proxy risk indicators. PARTICIPANTS AND SETTING: Low-income families (N = 1647) with children aged three to five years who completed the FMI were linked to their insurance records. METHODS: Multivariable logistic and generalized linear regression models were fitted to explore the association between the number of ACEs (FMI-ACEs scores) and healthcare utilization and health outcomes. RESULTS: Children were exposed at rates of 32.4 % to zero, 31.7 % to one, 19.7 % to two, and 16.3 % to three or more ACEs. The FMI-ACEs scores were associated with greater use of non-preventive outpatient visits, filled prescriptions, and overall use of healthcare. Incidences of adjustment disorders were 4 times and attention-deficit conducts were 2 times higher among children with the highest FMI-ACEs scores than those with zero FMI-ACEs. CONCLUSIONS: This study marks the first effort to conduct insurance claims data review to ascertain association between a survey measure of ACEs and health utilization and diagnosed conditions. The association of ACEs risk screening and healthcare utilization and diagnoses was observed.

Safety Baby Shower Intervention Improves Safe Sleep Knowledge and Self-Efficacy among Expectant Teens.

Introduction: Young, minority women are less likely to follow recommendations to prevent infant sleep-related deaths putting their children at risk. This study extended the past pre/post study designs to an RCT design and included both parent report and objective observation of the sleep environment. Objective: This study focused on this population in a quantitative, randomized controlled trial using a low-cost, brief educational intervention, a Safety Baby Shower (SBS). Methods: Pregnant teens aged 13-19 (N = 147) were recruited as a dyad with a senior female caregiver and randomized to intervention or control groups. Results: Comparing self-report, safe sleep knowledge, attitudes, beliefs, and intent (KABI) to act scores across the two groups found intervention dyads to have more positive views on all four constructs than controls. Specifically, intervention dyad young mothers were significantly more likely to have positive beliefs about safe sleep and were more likely to report intent to practice infant safe sleep than control young mothers. Intervention dyad young mothers also had higher self-efficacy related to infant safety and more positive attitudes about safe sleep practices than control young mothers. Observations at a home visit conducted after delivery found no differences in the safe sleep practices by intervention status. Participant report of behaviors at the home visit also showed no differences in the use of safe position between the intervention and control groups. Conclusion: It appears that even when young mothers gain knowledge and self-efficacy, they have difficulty implementing this knowledge. In practice, this suggests that exploring barriers prenatally with this population and offering suggestions to overcome them may be indicated.

Effects of home visiting on adolescent mothers' parenting attitudes.

We examined the impact of a home visiting intervention on 227 adolescent mothers' parenting attitudes. At enrollment, half of mothers were at risk for child maltreatment. Mothers assigned to intervention (n = 161) received home visits and case management. Intervention and comparison mothers (n = 66) participated in monthly peer group meetings. Regression analyses controlling for enrollment differences indicated that intervention group mothers had significant improvements in 3 of 5 subscales and in total Adult-Adolescent Parenting Inventory-2 scores relative to the comparison group.

Improved classroom quality and child behavior in an Arkansas early childhood mental health consultation pilot project.

The aim of the current study was to examine the effects of early childhood mental health consultation (ECMHC) on teacher-level and child-level outcomes in the context of a partnership between community mental health centers in three regions of Arkansas and publically funded early education programs (14 intervention sites and 4 comparison sites). From 2005 to 2008, 193 teachers participated in the study, along with 1,448 children. Data-collection activities included structured classroom observations, teacher ratings of children's strengths and behavior, and teacher surveys to assess satisfaction with ECMHC services. Results suggest that teachers were highly satisfied with the consultation services and that teachers receiving the intervention had lower levels of permissiveness and detachment, with a trend toward higher levels of sensitivity in interactions with children in their classroom. In terms of child outcomes, we found that by the third year of the project, children at intervention sites were rated by their teachers as having fewer behavior problems and more protective factors.

Predictors of sustainment of two distinct nutrition and physical activity programs in early care and education.

Introduction: The goal of the present study was to investigate factors associated with sustainment of two evidence-based programs for nutrition promotion in early care and education (ECE) settings - Food Friends (FF) and Together, We Inspire Smart Eating (WISE). Materials and methods: In a cross-sectional study design, ECE directors (N = 55) from centers that had previously been trained in WISE or FF completed a survey. Program-specific measures included Steckler's Perception of Innovations, the Program Sustainability Assessment Tool (PSAT), and the Organizational Readiness for Change Assessment (ORCA). For our primary outcomes, two measures of sustainment were examined: Nutrition Continued Practice (i.e., the use of or general focus on nutrition programs) and Program Fidelity (i.e., how well centers used specific evidence-based practices of WISE or FF). Multiple regression was used to determine the association of these outcomes with program, years since last implementation, and overall scores on predictors. Follow-up correlation analyses were used to investigate outcome relationships with context submeasures due to high intercorrelations between predictor submeasures. Results: Nutrition Continued Practice was significantly predicted by program and overall PSAT score. WISE programs had significantly higher Nutrition Continued Practice scores than FF program (p = 0.03). All subscales of the PSAT (e.g., environmental support, funding stability, organizational capacity, program adaptation, communications, and strategic planning) were significantly correlated with Nutrition Continued Practice (all rs > 0.30, all ps < 0.03). Program Fidelity was significantly predicted by PSAT and Steckler Perception of Innovation scores. All subscales of the PSAT were strongly positively correlated with Program Fidelity (all rs > 0.48, all ps < 0.001); relative advantage (r = 0.54, p < 0.001) and level of institutionalization (r = 0.61, p < 0.001) were positively correlated with Program Fidelity. Conclusion: This study suggests that factors associated with the continued practice of program principles are partially distinct from those that are associated with the sustainment of specific practices driving program fidelity. Results suggest capacity building strategies may be important for both continued attention to nutrition and physical activity as well as sustaining fidelity to specific evidence-based practices.

Obesity prevention practices in early care and education settings: an adaptive implementation trial.

BACKGROUND: Despite the potential for Early Care and Education (ECE) settings to promote healthy habits, a gap exists between current practices and evidence-based practices (EBPs) for obesity prevention in childhood. METHODS: We will use an enhanced non-responder trial design to determine the effectiveness and incremental cost-effectiveness of an adaptive implementation strategy for Together, We Inspire Smart Eating (WISE), while examining moderators and mediators of the strategy effect. WISE is a curriculum that aims to increase children's intake of carotenoid-rich fruits and vegetables through four evidence-based practices in the early care and education setting. In this trial, we will randomize sites that do not respond to low-intensity strategies to either (a) continue receiving low-intensity strategies or (b) receive high-intensity strategies. This design will determine the effect of an adaptive implementation strategy that adds high-intensity versus one that continues with low-intensity among non-responder sites. We will also apply explanatory, sequential mixed methods to provide a nuanced understanding of implementation mechanisms, contextual factors, and characteristics of sites that respond to differing intensities of implementation strategies. Finally, we will conduct a cost effectiveness analysis to estimate the incremental effect of augmenting implementation with high-intensity strategies compared to continuing low-intensity strategies on costs, fidelity, and child health outcomes. DISCUSSION: We expect our study to contribute to an evidence base for structuring implementation support in real-world ECE contexts, ultimately providing a guide for applying the adaptive implementation strategy in ECE for WISE scale-up. Our work will also provide data to guide implementation decisions of other interventions in ECE. Finally, we will provide the first estimate of relative value for different implementation strategies in this setting. TRIAL REGISTRATION: NCT05050539 ; 9/20/21.

Does the quality of stimulation and support in the home environment moderate the effect of early education programs?

The current study was designed to investigate how the quality of stimulation and support available to children in the home interacts with participation in Early Head Start to determine children's development. Data were obtained as part of the national evaluation of Early Head Start (EHSRE), a randomized trial involving 3,001 children and families from 17 program sites. Hierarchical linear regression analyses were used to examine the interaction of EHS with (a) early maternal emotional warmth and (b) provision of a stimulating home environment on children's development at ages 3 and 5. Findings showed EHS sometimes differentially benefited children who came from households where the levels of warmth and stimulation were lowest. However, there was evidence of other forms of moderation as well.

Testing maternal depression and attachment style as moderators of Early Head Start's effects on parenting.

This study examined maternal depression, attachment avoidance, and attachment anxiety as moderators of Early Head Start's effects on four parenting outcomes assessed at age three. Participants (N = 947) were drawn from six sites of the Early Head Start National Research and Evaluation Project, a multi-site randomized trial. Findings suggest more positive program effects for mothers with less initial attachment avoidance or attachment anxiety. First, baseline attachment avoidance moderated Early Head Start program effects on observed maternal supportiveness, such that program mothers with lower baseline attachment avoidance were rated as more supportive of their three-year-olds than program mothers with higher baseline attachment avoidance. Second, program effects on spanking varied depending on mothers' baseline attachment anxiety.

A mixed-methods protocol for identifying successful sustainability strategies for nutrition and physical activity interventions in childcare.

BACKGROUND: Despite the importance of sustainability for nutrition and physical activity in public health interventions, limited studies have explored the factors that promote and inhibit evidence-based program sustainment in the childcare setting. This study protocol describes a mixed-methods approach to develop novel sustainability strategies based on real-world settings and stakeholder feedback, with the goal of providing support for future obesity prevention programs and related studies on intervention sustainability. Two interventions, Together, We Inspire Smart Eating (WISE) and The Food Friends' (FF) Fun with New Foods and Get Movin' with Might Moves, are studied to this end. METHODS: The study will deploy an explanatory, sequential mixed-methods design. First, the research team will collect a quantitative survey to assess rates of sustainment among WISE and Food Friends sites. We expect to collect 150 surveys from WISE and FF sites combined. Data from these surveys will be used to purposively sample sites for 12 to 18 site visits. Specifically, we will purposively sample low, partial, and high sustaining sites where we will conduct key informant interviews and focus groups as well as validate self-reports on sustainability. Survey content, qualitative interviews, and coding will be based on the Dynamic Sustainability Framework. We will draw on findings from the quantitative survey on predictors of sustainment and the qualitative site visits to understand varying levels of program sustainment. Then, we will utilize evidence-based quality improvement sessions to engage stakeholders in developing a multi-component sustainability strategy. DISCUSSION: This study will provide a stakeholder-informed sustainability strategy ready for testing in a full-scale trial examining effects on sustainment of evidence-based nutrition and physical activity practices in childcare. We expect this strategy to be relevant for educators and consistent with the views of administrators as a guide for future practice for the targeted nutrition and physical activity interventions and beyond.

Stakeholder selected strategies for obesity prevention in childcare: results from a small-scale cluster randomized hybrid type III trial.

BACKGROUND: Together, We Inspire Smart Eating (WISE) is an intervention for the early care and education setting to support children's exposure to and intake of fruits and vegetables. WISE emphasizes 4 evidence-based practices (EBPs): (1) use of a mascot; (2) educators' role modeling; (3) positive feeding practices; and (4) hands-on exposures. The current study reports on a small-scale implementation trial aimed at improving the use of WISE EBPs by teachers. METHODS: A Hybrid Type III Cluster Randomized Design compared a Basic and Enhanced implementation strategy. The Basic Strategy included training and reminders only; the Enhanced strategy was a multi-faceted package of stakeholder-selected strategies including a leadership commitment, an implementation blueprint, a local champion, an environmental reminder of the EBPs, facilitation, and tailored educational resources and incentives. All study sites were Head Starts. Sites were randomized using a balancing technique that considered site characteristics; 4 sites (20 classrooms, 39 educators, 305 children) received Enhanced support; 5 sites (18 classrooms, 36 educators, 316 children) received Basic support. RE-AIM guided the evaluation, and implementation fidelity was the primary outcome. Strategies were assessed using examination of data distributions and unadjusted comparisons (t tests) as well as general linear and mixed effects models controlling for covariates. RESULTS: For the primary outcome of fidelity, the Enhanced group had significantly higher means for 3 of 4 EBPs. Multivariate models explained a significant portion of variance for both mascot use and hands-on exposure with a significant positive effect observed for treatment condition. The Enhanced group also had higher rates of Appropriateness and Organizational Readiness for Implementing Change (as indicators of implementation and adoption, respectively). There was no significant difference between groups for indicators of Reach, Effectiveness or Maintenance. Formative interviews indicated key targets for iteration and potential mechanisms. Key events were catalogued to provide context for interpretation (e.g., 61% of classrooms with turnover). CONCLUSIONS: Findings were mixed but suggested promise for the Enhanced strategy, especially considering key events of the study. Implementation fidelity improvements occurred mainly in the last 3 months of the school year; additional time may be needed to translate to improvements in child outcomes. TRIAL REGISTRATION: NCT03075085 Registered 20 February 2017.

HIV Stigma: A Clinical Provider Sample in the Southern U.S.

PURPOSE: Dimensions of HIV Stigma perceptions have not been examined in medical providers in the southern U.S. This study examined the prediction of HIV knowledge on multiple dimensions of stigma beliefs. METHODS: We assessed clinical staff (N = 153) in rural clinics (2017) HIV stigma beliefs and knowledge. Using multiple regression, we examined the ability of knowledge to predict stigma beliefs organized into meaningful dimensions. RESULTS: There was high variability in HIV knowledge among the medical professionals surveyed with a score of 70/100 (i.e., a 'C'). Of the five stigma factors explored, only two had a score greater than 80 (ie., a 'B' score on the 'test'). Controlling for demographic factors, there was a significant effect of HIV Knowledge on Discrimination (F (4,146) = 2.02, p = 0.03), Prejudice (F (4,146) = 2.13, p = 0.04), Service Provision (F (4,145) = 2.30. p = 0.02), and Perceived Risk in Practice (F (4,91) = 5.75, p < 0.01). CONCLUSIONS: The relatively low knowledge score and link between knowledge and stigma beliefs indicated a need for continued basic HIV education. Increased education around HIV risk is critical in the eradication of HIV given the link between high stereotyping beliefs and low testing rate.