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Clinical practice guidelines and evidence-based reviews confirm the efficacy of tobacco dependence treatment for pregnant women. The purpose of this study was to examine tobacco dependence treatment practices among certified nurse-midwives who treat pregnant women who smoke. Midwives were surveyed to determine knowledge, perceptions, and beliefs about tobacco cessation treatment and to identify practice environmental factors that support treatment practices. Half of all midwives had not heard of the US Public Health Service Guidelines (5 A's) to assist smokers in cessation treatment. We found varying levels of adherence to the clinical practice guidelines. Nearly all midwives routinely ask, advise, and assess; while fewer encourage patients to set a quit date or discuss medication options (assist) and perform follow-up activities (arrange). Barriers significantly associated with clinical tobacco treatment practice are lack of training and competing priorities in the visit. One-office support, a system in place to provide smoking cessation information and resources, was associated with increased practice. In summary, midwives believe they should be providing tobacco dependence treatment, yet they identify a need for training. The findings of this study also indicate that sustained practice change, which includes the entire practice environment, should be targeted to enhance tobacco dependence treatment. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the agreement between 2 measures (adult vs adolescent) of current cigarette smoking among young adults. METHODS: We examined data from 1007 young adults from the New Jersey Adult Tobacco Survey. The adult measure incorporates lifetime and present use, whereas the adolescent measure assesses past 30-day use. The kappa coefficient was used to determine agreement between the 2 current cigarette smoking measures. RESULTS: Agreement between the measures was high, but not ideal. The percent reporting smoking in the past 30 days but not 100 cigarettes in their lifetime was notably higher, and therefore agreement was lower, for black females, Hispanic males, and college students living on campus. CONCLUSIONS: Sole use of the adult or adolescent measure of current cigarette smoking is insufficient to document progression to regular smoking in young adults. [ABSTRACT FROM AUTHOR]

War and social transition in Croatia have increased unemployment and rates of substance abuse. A decrease in prevention programs places adolescents at an increased risk. Data collected from the 2002 Split Youth Behavior Risk Survey (YRBS) showed that adolescents are at risk for alcohol use and related problems. Thus, there is a need to strengthen primary and secondary prevention activities to empower adolescents and counteract negative societal change. A public health partnership between the University of Medicine and Dentistry of New Jersey-School of Public Health (UMDNJ-SPH) and Split, Croatia was formed in 2001. Adolescent alcohol prevention was identified as our focus and Project Northland, a model U.S. program, was selected. A strong network of NGOs and government officials support the project. Qualitative evaluation showed strong parent, teacher, and student satisfaction. Preliminary analysis shows a heightened awareness on the part of students that will likely contribute to the overall success of the program. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify characteristics associated with youth bidi use. METHODS: The New Jersey Youth Tobacco Survey is a self-administered school-based survey that uses a 2-stage cluster sample design to obtain a representative statewide sample; 9589 students (grades 7-12) participated. Logistic regression was used to generate an adjusted odds ratio (OR) for current bidi use for each variable, controlling for gender, race, and school grade. RESULTS: Higher odds for current bidi use were noted for black and Hispanic students, users of other tobacco products, and students that perceived bidis as safer than cigarettes. CONCLUSIONS: These results suggest specific groups that should be targeted for intervention. [ABSTRACT FROM AUTHOR]

While multiple risk factors are associated with smoking, body weight concern is a significant risk factor for smoking among young women, including adolescents. This article explores the relationship between frequency of smoking and weight loss strategies among a nationally representative sample of high school females (n = 7,828). Adjusted odds ratios were generated for smoking, weight goals, and weight loss strategies, controlling for demographics. Daily smokers were two to four times more likely to fast, use pills, and purge to control their weight than nonsmokers. Tobacco control efforts for young women must address the influence of weight concern on smoking in this population. [ABSTRACT FROM AUTHOR]

Chronic hepatitis B infection is a leading cause of liver cancer worldwide. In the USA, African immigrants (AI) have high hepatitis B virus (HBV) infection rates but low HBV knowledge and screening rates. Research about HBV among AI living in Philadelphia is particularly limited. This study aims to assess barriers to and factors influencing HBV screening in the Philadelphia AI population. African and Caribbean-born adults in Greater Philadelphia were recruited for phone interviews at community health fairs hosted by the African Cultural Alliance of North America (ACANA) and the African Family Health Organization (AFAHO) in partnership with the Hepatitis B Foundation. Seventeen interviews were recorded, transcribed, and coded independently by two members of the research team using NVivo software. Themes and subthemes were created by analysis of the codes and arranged under Health Belief Model (HBM) concepts. Major perceived barriers included lack of HBV knowledge and awareness and cultural challenges related to health care access, preventive care, fear, and stigma. Participants recommended using community organizations and programs to spread awareness about HBV and serve as cues to action. In-person education was emphasized due to lack of access to and knowledge of technology such as Zoom. While HBV educational sessions have been implemented in this population, they have not been consistent or far-reaching. The results of this study can contribute to the implementation of a comprehensive AI-specific HBV education and screening program through partnerships with community organizations to ensure that all high-risk individuals in the Philadelphia area are screened., Competing Interests: Declarations The authors have no relevant financial or non-financial conflicts of interest to disclose. Ethics Approval All study participants provided verbal consent before being interviewed in accordance with federal regulations that allow waiver of signed consent. This study was determined to be exempt from IRB review by the Jefferson Institutional Review Board Competing Interests All authors have no competing interests to disclose., (© 2023. W. Montague Cobb-NMA Health Institute.)

Objectives: Our study evaluated if rapid inpatient titration of methadone for pregnant patients with opioid use disorder (OUD) improved outcomes without increasing the risk for overdose., Methods: This is a retrospective cohort study of pregnant patients admitted for inpatient methadone titration from January 2020 to June 2022. Outcomes were compared between standard versus rapid titration protocols. Standard titration involved an initial methadone dose with additional doses every 6 hours if clinical opiate withdrawal score (COWS) is >9. Rapid titration involved an initial methadone dose with additional doses every 4 hours if COWS is >9. The primary outcome was time required to achieve stable dose. Secondary outcomes included elopement prior to achieving stable dose, methadone-related readmission, opioid overdose, and final dose., Results: There were 97 patients in the standard titration (STP) and 97 patients in the rapid titration (RTP) groups. Demographic characteristics and substance use history did not differ between the 2 groups. Time to stable dose did not differ between the 2 groups (RTP, 5.0 days ±4.0; STP, 4.0 days ±3.0; P = 0.08). Patients in the rapid titration group were less likely to elope from the hospital prior to stabilization (RTP 23.0% vs STP 37.9%, P = 0.03) and had fewer methadone-related readmissions ( P < 0.001). One patient (1.0%) in the RTP group required naloxone treatment while inpatient for concern for overdose, while none did in the STP group ( P = 0.32). There was no difference in median final stable dose between the 2 groups ( P = 0.07)., Conclusions: Rapid titration of methadone for pregnant patients with OUD was associated with decreased medical elopement and methadone-related readmission, without increasing the risk for overdose., Competing Interests: Conflict of Interest Statement: The authors have no conflicts of interest to declare., (Copyright © 2024 American Society of Addiction Medicine.)

Introduction: Research about the application of shared decision-making (SDM) in the context of Medication Assisted Treatment (MAT) for pregnant women with opioid use disorder (OUD) is limited. The objectives of our study were to 1) examine facilitators of and barriers to SDM for the initiation of MAT in clinical practice and 2) evaluate the receptivity of clinicians and doulas involved in the care of women with OUD to the use of an online software application to facilitate SDM about MAT., Methods: This qualitative study utilized semi-structured interviews with consenting physicians and doulas who provided care for pregnant women with OUD between November 2021 and May 2022. Participants were asked about factors influencing SDM in practice. In addition, the study asked participants about the feasibility of using the Jefferson Decision Counseling Guide© (JDCG) to educate pregnant women with OUD as to the benefits and risks of undergoing MAT versus no treatment and to help patients clarify their treatment preference. The study recorded the interview and transcribed it verbatim using Rev. transcription services. The study used thematic analyses to code the data and identify key barriers and facilitators of SDM and perceptions of the SDM tool., Results: Nineteen participants completed interviews. The study identified several barriers to SDM including time constraints, lack of decision counseling tools at points of care, and patients presenting in an actively high state or withdrawing. Peer workers or other trained personnel, giving patients more time, and comfort in decision counseling are examples of facilitators identified by the participants of the study. Participants believed that the counseling tool could facilitate conversations with patients and should be integrated into the workflow., Conclusion: In this qualitative study, we identified several barriers and facilitators of SDM to initiate MAT for pregnant women with OUD. Our findings indicate that there are challenges and opportunities for healthcare systems to increase SDM in this marginalized patient population. Feedback from participants highlighted their receptivity to the use of SDM tools to facilitate meaningful conversations in various settings that can guide decision making about care., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Ruth Jeminiwa reports that financial support was provided by The American Association of Colleges of Pharmacy. Ronald Myers has a copyright, The Jefferson Decision Counseling Guide Copyright, issued to Thomas Jefferson University and Ronald Myers. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The goal of this study was to describe the development of an educational brochure for pregnant women with opioid use disorders (OUDs) about treatment options. Based on findings from a preliminary review of the literature, we drafted a brochure that addressed the following questions: (1) What are your options (Medication-Assisted Treatment (MAT) versus no treatment)? (2) What are the benefits of MAT? (3) What are the risks of MAT? (4) Can I take buprenorphine or methadone while breastfeeding? (5) Which medication should I choose? Clinicians and doulas (n = 19) who provide care to pregnant women with OUDs were recruited. Semi-structured interviews elicited participants' feedback on brochure content and their perceptions about brochure use for patient education. Thematic data analyses were performed. Three emergent themes were identified (suggested uses and settings of use, content revisions, and perceptions about the brochure) and used to refine the final brochure. This study provides valuable insights into the desired content of an educational brochure describing treatment options for pregnant women with OUDs from the provider's standpoint. Research is needed to assess the use of the brochure in shared decision-making conversations with providers about treatment.

Introduction: The effectiveness of group prenatal care (G-PNC) compared with individual prenatal care (I-PNC) for women with opioid use disorder (OUD) is unknown. The objectives of this study were to (1) assess the acceptability of co-locating G-PNC at an opioid treatment program and (2) describe the maternal and infant characteristics and outcomes of pregnant women in treatment for OUD who participated in G-PNC and those who did not., Methods: This was a retrospective cohort study of 71 women (G-PNC n = 15; I-PNC n = 56) who were receiving treatment for OUD from one center and who delivered in 2019. Acceptability was determined by assessing the representativeness of the G-PNC cohorts, examining attendance at sessions, and using responses to a survey completed by G-PNC participants. The receipt of health services and healthcare use, behaviors, and infant health between those who participated in G-PNC and those who received I-PNC were described., Results: G-PNC was successfully implemented among women with varying backgrounds (e.g., racial, ethnic, marital status) who self-selected into the group. All G-PNC participants reported that they were satisfied to very satisfied with the program. Increased rates of breastfeeding initiation, breastfeeding at hospital discharge, receipt of the Tdap vaccine, and postpartum visit attendance at 1-2 weeks and 4-8 weeks were observed in the G-PNC group compared with the I-PNC group. Fewer G-PNC reported postpartum depression symptomatology., Conclusion: Findings suggest that co-located G-PNC at an opioid treatment program is an acceptable model for pregnant women in treatment for OUD and may result in improved outcomes., (© 2023 Wiley Periodicals LLC.)

Background and Objectives: Parenting women in treatment for opioid use disorder (OUD) report a lack of family centeredness and anticipatory guidance within well child care (WCC), and WCC utilization is low among affected children. We explore priorities for WCC visit content to inform primary care recommendations for this population., Methods: This study is a qualitative study of parenting women from one urban, academic OUD treatment program and pediatric primary care clinicians from a nearby affiliated pediatric practice. Eligible parent participants had a child ≤2 years old and were English speaking. Semistructured interviews elicited perspectives on WCC, with questions and prompts related to visit content. Inductive thematic analysis was led by 2 investigators using open coding procedures., Results: Among 30 parent participants, the majority were White (83%) and unmarried (90%). Approximately 60% reported their child received pharmacotherapy for neonatal opioid withdrawal syndrome. Of 13 participating clinicians, 9 were attending pediatricians. Five themes emerged from parental and clinician interviews: (1) improving knowledge and confidence related to child development, behavior, and nutrition; (2) mitigating safety concerns; (3) addressing complex health and subspecialty needs through care coordination; (4) acknowledging parental health and wellbeing in the pediatric encounter; and (5) supporting health education and care related to neonatal opioid withdrawal syndrome. Parents and clinicians expressed difficulty comprehensively addressing such issues due to time constraints, social determinants of health, and significant informational needs., Conclusions: Parenting women in treatment for OUD and pediatric clinicians share multiple priorities for anticipatory guidance within WCC visits and barriers to addressing them comprehensively., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 American Society of Addiction Medicine.)

Objective: The objective of this study was to describe breastfeeding intention, knowledge, and attitude, and sources of infant feeding information during the prenatal period among a cohort of pregnant women in treatment for opioid use disorder (OUD)., Study Design: Pregnant women who were receiving treatment for OUD and in the third trimester completed a questionnaire that measured demographic characteristics, infant feeding intentions, breastfeeding beliefs and attitudes, and sources of breastfeeding information. Frequency counts and percentages and means and standard deviations were used to describe data., Results: Sixty-five women completed the survey. Three-fourths reported some intention to breastfeeding. While attitudes around breastfeeding were generally positive, less than half of respondents knew the recommendations and infant health benefits of breastfeeding., Conclusion: Prenatal programs for women in treatment for OUD should consider addressing patient-reported concerns and gaps in knowledge regarding the benefits of and recommendation for breastfeeding., Key Points: · Breastfeeding has unique benefits for mother-infant dyads affected by maternal OUD.. · Breastfeeding decisions are influenced by maternal psychosocial factors (e.g., knowledge and attitudes), however, such factors have not been previously assessed in women in treatment for OUD.. · Results indicate that attitudes around breastfeeding are positive but knowledge gaps exist.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: For parents with opioid use disorder (OUD) and their children, group well child care (WCC) is an under-studied intervention that may reduce stigma, increase quality of care, and improve clinical outcomes. We explored barriers and facilitators to this intervention using an implementation science framework., Methods: A qualitative study was conducted from October 2020-March 2021 as part of the planning phase of a cluster-randomized trial of group WCC. Parent participants were recruited from one urban, university-affiliated OUD treatment center to participate in semi-structured telephone interviews. Eligible parents had a child under two years old and were English speaking. Clinician participants were recruited from a nearby pediatric primary care practice. Inductive thematic analysis of interview responses was led by two investigators using open coding procedures., Results: Thirty-one parents and thirteen pediatric clinicians participated in the interviews. Most parents (68%) reported that they would be likely or very likely to bring their child to the OUD treatment center for WCC. Six themes emerged describing perceived implementation barriers, including intervention difficulty, complexity, and potential negative outcomes such as loss of privacy. Six themes emerged as implementation facilitators: (1) focus on parental OUD and recovery, (2) peer support, (3) accessibility and coordination of care, (4) clinician skill and expertise in parental OUD, (5) increased time for patient care, and (6) continuity of care., Conclusions for Practice: Parents and clinicians expressed multiple perceived benefits of this intervention. Identified barriers and facilitators will inform implementation and evaluation of group WCC within one OUD treatment program., (© 2023. The Author(s).)

Purpose: To describe the prevalence of food insecurity among pregnant and parenting women with opioid use disorder (OUD), its association with psychosocial health, and their experience with the Special Supplemental Nutrition Program for Women Infant Child (WIC) program., Design: This cross-sectional study collected survey data through REDCAP., Setting: The study was conducted at a single, urban, opioid treatment program., Subjects: A total of 91 female participants (≥18 years of age and receiving OUD treatment services) were approached about the study and all consented., Measures: Measures included: US Household Short Form Food Security Survey, Patient Health Questionnaire 4(PHQ4), Perceived Stress Scale (PSS), and a demographics and food behavior survey., Analysis: Descriptive analyses (frequency, means) described data and Chi-Square, Fischer's exact, t -tests were used to compare data between food security groups., Results: Participants were on average 34 years old, Caucasian (68%), and non-Hispanic (87%). Most reported low (32%) to very low (33%) food security. Pearson correlation analyses indicate a strong positive linear relationship between Food Security Score and PHQ4 Total ( P = .0002), PHQ4 Depression ( P = .0003), PHQ4 Anxiety ( P = .0009), and PSS Total ( P < .0001). Only 38% felt the foods available in WIC supported their breastfeeding. Limitations include a single site and recall bias., Conclusions: Significant nutritional inequity in families affected by maternal substance use exists, with potential for adverse maternal and child development related implications., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Studies suggest that group-based well child care-a shared medical appointment where families come together as a group to receive pediatric primary care-increases patient-reported satisfaction and adherence to recommended care. Evidence supporting the use of group well child care for mothers with opioid use disorder, however, is lacking. The overall objective of the Child Healthcare at MATER Pediatric Study (CHAMPS) trial is to evaluate a group model of well child care for mothers with opioid use disorder and their children., Methods: CHAMPS is a single-site 2-arm cluster randomized controlled trial. A total of 108 mother-child dyads will be enrolled into the study. Twenty-six clusters of approximately 4 mother-infant dyads each will be randomized 1:1 to one of two study arms (intervention or control). Clustering will be based on child's month of birth. In the intervention arm, group well child care will be provided on-site at a maternal substance use disorder treatment program. Mother-child dyads in the control arm will receive individual well child care from one nearby pediatric primary care clinic. Dyads in both study arms will be followed prospectively for 18 months, and data will be compared between the two study arms. Primary outcomes include well child care quality and utilization, child health knowledge, and parenting quality., Discussion: The CHAMPS trial will provide evidence to determine if a group well child care offered on-site at an opioid treatment program for pregnant and parenting women is beneficial over individual well child care for families impacted by maternal opioid use disorder., Trial Registration: ClinicalTrials.gov identifier: NCT05488379. Registered on Aug. 04, 2022., (© 2023. The Author(s).)

Objective: Previous research suggests gaps in well-child care (WCC) adherence, quality, and effectiveness for children impacted by parental opioid use disorder (OUD). The objective of this study was to gather in-depth information regarding maternal and clinician-reported factors that enhance ("facilitators") or hinder ("barriers") WCC engagement as well as mothers' experiences during WCC visits., Methods: Thirty mothers who were in treatment for OUD and 13 clinicians working at a pediatric primary care clinic participated in this qualitative study. All participants completed one data collection telephone session which involved a brief questionnaire followed by a semi-structured interview. Thematic analyses of the interview transcripts were conducted using an inductive approach., Results: Three broad themes were identified as facilitators of WCC by mothers and clinicians, including: 1) continuity in care, 2) addressing material needs, and 3) clinician OUD training and knowledge. Themes identified as barriers to WCC included: 1) stigma toward mothers with OUD, 2) gaps in basic parenting knowledge, 3) competing specialized health care needs, and 4) insufficient time to address all concerns., Conclusion: WCC programs or clinical pathways designed for families affected by maternal OUD should consider these barriers and facilitators of WCC engagement and affect experiences of WCC for mothers and clinicians., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: Characterizing common concerns for children with intrauterine opioid exposure (IOE) can inform tailored primary care., Methods: Retrospective analysis of primary care data of children with IOE from birth to age two years within one multi-state pediatric health system. Well child care (WCC) and problem-based visit diagnoses were categorized, and descriptive statistics were tabulated., Results: Three hundred and eighty-five (385) children with IOE had 3,622 primary care visits, of which 51.4% were WCC and 48.6% were problem-based. Most frequent visit diagnoses were upper respiratory complaints (14.8% of visits), feeding difficulties (12.2%), and perinatal viral exposure (9.8%). Although visit type (WCC vs. problem-based) varied across diagnostic category, frequent utilization of both visit types were documented for several diagnoses in infancy (e.g., fussiness/colic, feeding difficulties)., Conclusions: Well child care visits for children with IOE are key opportunities for anticipatory guidance with an emphasis on problems that may contribute to acute health care utilization, particularly in early infancy.

Objective: To assess the utilization of preventive health services and the prevalence of chronic health conditions among a cohort of women in treatment for opioid use disorder (OUD)., Methods: Ninety-seven women who were receiving treatment for OUD from a single urban treatment program completed a self-administered anonymous online questionnaire that asked about demographics, health, receipt of preventive health services, and utilization of health care. Descriptive statistics were used to describe data., Results: More than one-third of respondents reported that their health was fair or poor, whereas one-quarter were very concerned with their health. Most participants (59%) reported at least one chronic health condition; nearly 1 in 5 reported two or more conditions. Less than half of respondents had received a routine medical examination in the past year. Vaccine uptake was low; 56% received the coronavirus disease 2019 vaccine and 36% received the annual influenza vaccine., Conclusions: Women in treatment for OUD could benefit from enhanced health care to address the high rates of chronic diseases and risk factors and underutilization of recommended preventive health services. Interventions and models of care that aim to enhance utilization of such services, and ultimately improve the health of this vulnerable population, may be worth exploring., Competing Interests: The authors declare that they have no conflict of interest. No financial disclosures were reported by the authors of this article., (© Vanessa L. Short et al., 2022; Published by Mary Ann Liebert, Inc.)

Background: Medications for opioid use disorder, including methadone, combined with comprehensive wraparound services, are the gold standard for treatment in pregnancy. Higher methadone doses are associated with treatment retention in pregnancy and relapse prevention. Given known inequities where individuals of color tend to be prescribed lower doses of opioids for other conditions, the purpose of this study was to determine whether there is racial inequity in methadone dose at delivery in pregnant women with opioid use disorder., Methods: Retrospective review of medical charts identified pregnant women (N = 339) treated with methadone for opioid use disorder during pregnancy at one center from 2012 to 2017. Variables extracted from medical records included race, demographic and relevant clinical information (e.g., methadone dose at delivery, height, weight, etc.). Analyses used simple and multiple linear regressions to determine associations between these characteristics and methadone dose at delivery., Results: The mean methadone doses at delivery among women of color and white women were 105.8 mg and 144.9 mg, respectively (p < .0001). After adjusting for maternal age, gestational age at delivery, body mass index, type of opioid used, and parity, race was significantly and independently associated with methadone dose at delivery, with women of color receiving 36.2 mg less than white women (p = .0003)., Conclusions: Pregnant women of color with opioid use disorder received 67% of the dose of methadone at delivery that white women received. Antiracist responses to prevent provider bias in evaluating dose needs are needed to correct this inequity and prevent undertreatment of opioid use disorder among women of color., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: The U.S. has the highest rate of preterm birth (PTB), of all developed countries, especially among African American women. Social determinants of health and inequalities in health outcomes are understudied areas. The intersectionality of race and socioeconomic status has been shown to contribute to chronic stress, stress has been shown to be associated with PTB, yet the mechanisms that affect pregnancy outcomes have not been explicit. Mindfulness-based Interventions that address stress reduction during pregnancy may improve quality of life during pregnancy, perhaps enhancing resilience, and be on the pathway to reducing the risk of negative pregnancy outcomes such as PTB., Methods: We over-enrolled African American women and those covered by Medicaid to reach women at higher risk for PTB and included women in substance use treatment. Participants were enrolled in a 6-week mindfulness in pregnancy (MIP) intervention at the obstetric clinic. Sociodemographic characteristics and psychosocial assessments were obtained at three time points., Results: We enrolled 35 women who self-identified as: non-white, Medicaid recipients, aged 25-35 years, with high school or less education. We found reductions in perceived stress, pregnancy specific stress, trait anxiety and depression and increases in mindfulness that sustained post-intervention at 2 and 7 months., Discussion: Social determinants and stress in particular have been associated with negative birth outcomes. This paper describes a brief intervention and results of MIP tailored to women who have significantly more stress due to race, poverty, homelessness, substance use treatment and other comorbid health risks including PTB., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Pregnant and parenting women with opioid use disorder face multiple challenges to recovery. Trauma histories, poverty, stigma and discrimination, and lack of access to treatment intersect to marginalise this population. It is important that pregnant and parenting women with opioid use disorder receive comprehensive care to improve their health, the health of their child(ren), and prevent the intergenerational transmission of opioid and other substance use disorders. For nearly 50 years the Maternal Addiction Treatment, Education, and Research program has provided an evolving and expanding range of comprehensive services for treating opioid and other substance use disorders in this population. In this review the rationale for, and processes by which, key components of a comprehensive approach are discussed. These components include patient navigation for access to care, low-barrier medications for opioid use disorder, effective trauma-responsive therapy, prenatal and well-child healthcare, and other support services that make it possible for pregnant and parenting women to engage in treatment and improve the health of the entire family. Additionally, a method for supporting staff to build resilience and reduce fatigue and burnout is discussed. These components comprise an effective model of care for pregnant and parenting women with opioid and other substance use disorders.

Effective communication is critical for therapeutic work with individuals, for the interdisciplinary team, and for leadership in a substance use disorder (SUD) treatment program. Prior to the COVID-19 pandemic, over a two-year period Thomas Jefferson University's Maternal Addiction Treatment, Education and Research (MATER) program, an SUD treatment program serving pregnant and parenting women living in an urban environment, implemented Mindfulness Dialogue for Life (MDfL) to deepen communication, encourage courageous conversations, bring more compassion to staff and patients, and improve trust among leadership. MDfL focuses on three stages-connecting, exploring, and discovering-and it uses mindfulness practices to enhance communication. Here we describe our efforts to implement MDfL on a virtual platform and how the COVID-19 pandemic affected staff's work experience, as identified during their MDfL sessions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Preventive paediatric healthcare is essential for infant and child health. Current research, however, suggests that the delivery of routine well child care (WCC) for children affected by maternal opioid use disorder (OUD) could be improved. How mothers perceive interactions with healthcare providers may help identify ways to modify the experience of WCC, which could ultimately improve healthcare utilization, patient satisfaction and clinical outcomes. The objective of this qualitative study was to assess perceptions of WCC among mothers in treatment for OUD., Methods: Four focus group sessions of 4-8 participants each (N = 22) were conducted. All study participants were receiving comprehensive behavioural and physical health support and care plus pharmacotherapy for OUD from a single outpatient treatment centre. Focus groups were semi-structured, with a standardized set of open-ended questions and follow-up prompts to engage participants in a fluid discussion. Participants were asked to identify and discuss important aspects of their youngest child's WCC and what they liked and disliked about their child's WCC. Grounded theory analysis was used to identify themes., Results: Several aspects of WCC were identified as important to the mothers. Main themes identified included (1) mother-provider relationship, (2) communication with healthcare team and (3) support for mother's OUD treatment. Participants discussed their desire to be heard and understood and wanted the entire healthcare team and clinic staff to see them as mothers first and foremost, not merely as individuals with OUD., Conclusion: Future attempts to refine care may consider healthcare models that highlight open communication and personalized care and offer strong support and ongoing encouragement for the mother's OUD treatment and recovery process., (© 2020 John Wiley & Sons, Ltd.)

Background: Pregnancy and the delivery of an infant mark a unique time of engagement in healthcare for women in treatment for opioid use disorder (OUD). The American College of Obstetrics and Gynecology calls for a comprehensive approach to perinatal healthcare delivery for pregnant women with OUD in order to facilitate improved health outcomes and increase patient-provider collaboration. Yet, there is little knowledge regarding the perceptions of women with OUD regarding the current delivery of healthcare which could inform a personalized, tailored approach to perinatal healthcare delivery. Methods: Four focus groups consisting of 22 women with OUD were conducted, transcribed, and analysed using qualitative thematic analysis methodology. Results: Women reported an overall lack of preparation for the birth and neonatal healthcare experiences and identified opportunities for greater support by the healthcare team. Women emphasized the desire for evidence-based preparation from trusted sources about delivery, neonatal abstinence syndrome, breastfeeding, and how their medications affect their pregnancy and baby. Women reported receiving a varied amount of support from healthcare providers in their transition to motherhood, but women predominantly reported receiving emotional and informational support from their mothers and partners. Conclusions: The knowledge obtained in this study points to gaps in perinatal healthcare delivery for women with OUD. Improving the delivery of perinatal healthcare may contribute to increased engagement by women with OUD, and ultimately improve outcomes for a vulnerable population.

Introduction: Given the increase of marijuana use among U.S. women, higher rates of unintended pregnancies among women who use marijuana, and potential consequences of maternal use, there is a need to identify factors associated with marijuana use in the period leading up to pregnancy. This study aims to provide estimates of preconception marijuana use and describe associations between preconception marijuana use and maternal characteristics among a population-based sample of recently delivered women in the U.S., Methods: This was an analysis of 2016 Pregnancy Risk Assessment Monitoring System data from 6 states (Louisiana, Maine, New Mexico, Vermont, Wisconsin, and Wyoming). Characteristics were compared between respondents who did and did not report marijuana use using chi-square tests and logistic regression models. Statistical analysis was performed in 2019 and 2020., Results: Approximately 8% of respondents reported that they had used marijuana in the month before pregnancy. After controlling for a number of factors, marital status, education level, parity, and living in a state with medical or recreational marijuana legalization or decriminalization remained independently associated with marijuana use. Those who reported marijuana use were 3-5 times more likely to also report symptoms of depression and tobacco and alcohol use before or during pregnancy than respondents who did not report marijuana use., Conclusions: Reproductive-aged women who are intending pregnancy or likely to experience an unintended pregnancy should be asked about and encouraged to refrain from marijuana use, especially given the strong association with depressive symptomology and concurrent use of other substances, including tobacco., (Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

To assess receipt of anticipatory guidance and family-centered care during well-child care (WCC) for children of mothers with opioid use disorder (OUD). Cross-sectional survey of 157 mothers receiving treatment for OUD who had a child < 3 years old and received primary care. Survey items evaluated (1) receipt of anticipatory guidance on 15 topics during WCC for the participant's child and (2) whether WCC was family-centered. The percentage of participants who reported guidance for each topic and the distribution of responses on family-centered items were calculated. A Pearson correlation was conducted to evaluate the association between the total number of topics for which anticipatory guidance was received and the family centeredness summary score. Receipt of anticipatory guidance varied by topic, ranging from 59% for guidance on childcare to 98% for guidance on safe sleep. Less than two-thirds of mothers reported that their child's provider "always" knew their child's medical history (56%), listened carefully (58%), clearly explained things (61%), and respected the mother (62%). Less than half reported that the provider spent enough time with them, and less than one-third reported that they were asked for their viewpoints. Anticipatory guidance and family-centeredness scores were positively correlated (r = 0.22, P = 0.006). Mothers with OUD report gaps in anticipatory guidance on important WCC topics, and limited family-centered care for their children. Further research may focus on refinements to the delivery of care for this population.

Background: Although current evidence suggests that there are unique benefits of breastfeeding for mothers receiving comprehensive treatment, including counseling and pharmacotherapy, for opioid use disorder (OUD) and their infants, breastfeeding rates in this population are low. Support and counseling about breastfeeding are key predictors of infant feeding behaviors. Thus, identifying knowledge and attitudes regarding breastfeeding of individuals who work in OUD treatment facilities could offer insight into targets for breastfeeding-promotion interventions in such settings. Materials and Methods: Individuals who work at two urban perinatal OUD treatment centers were e-mailed a link to complete a questionnaire electronically. Breastfeeding knowledge, attitudes, and perceptions of those who completed the questionnaire were described using descriptive statistics. Results: Among the 24 survey respondents, most correctly identified the health benefits of breastfeeding for infants with neonatal abstinence syndrome, whereas less than half correctly identified the health benefits of breastfeeding for all infants. Only 16% reported receiving work-related breastfeeding education. The leading perceived breastfeeding challenges for women in treatment for OUD were (1) concern with transfer of medication (e.g., methadone) through breast milk, (2) daily commutes for treatment, and (3) beliefs that formula is better than breastfeeding. Conclusions: Professionals who work in perinatal OUD treatment centers could benefit from education regarding breastfeeding in mothers in treatment for OUD.

Objectives: Practicing Safety is an American Academy of Pediatrics toolkit to help practices address child abuse and neglect (CAN) risk by increasing screening and providing resources. The objectives in an urban practice serving low-income children were to 1) standardize CAN risk assessment and developmental screening, and 2) improve resource provision., Methods: A quality improvement initiative to standardize CAN risk assessment, using materials adapted from Practicing Safety, was conducted through the use of SmartTools in an electronic health record. The Edinburgh Postnatal Depression Scale and Parents Evaluation of Developmental Status were used to assess maternal depression and child development, respectively. Charts were reviewed in waves-pre-, immediate post-, and early post-implementation (waves 1 to 3); monthly for 6 months (waves 4 to 9); and quarterly for 12 months (waves 10 to 13)-to assess screening and resource provision for 6 domains: infant crying, maternal depression, development, discipline, temper tantrums, and toilet training., Results: A total of 581 charts were reviewed (92, 95, and 94 for waves 1 to 3, respectively; 30 each for waves 4 to 13). Screening for infant crying, maternal depression, development, and discipline rose from 0% pre-implementation to over 50% post-implementation. Screening for temper tantrums and toilet training rose from 6% to 72% and from 36% to 82%, respectively. For all measures, resource provision improved over time, and all improvements were maintained for 1.5 years post-implementation., Conclusions: Incorporating an adapted version of Practicing Safety into an electronic health record is a practical and effective approach to improving CAN risk assessment and resource provision. This quality improvement initiative is an example of a practice-wide improvement that resulted in clinical practice change., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Child maltreatment is a significant public health issue in the United States. Yet, fewer than half of pediatricians discuss behavioral, developmental, or parenting issues with parents., Objective: This paper describes the testing of bundles of tools and processes, part of a larger intervention, Practicing Safety, targeted at changing physician and staff behavior to identify families at risk for child maltreatment, provide anticipatory guidance, refer to community resources, and follow-up and track at-risk families. The intervention was implemented with 14 pediatric primary care practices throughout the United States; the study was completed in 2011., Methods: A within-subjects repeated measures pre-post follow-up design was used to evaluate the intervention. Baseline and repeated measurements of pediatric practices' processes were collected using qualitative and quantitative methods. In total, 14 core improvement teams from across the country tested three bundles of tools (maternal, infant, toddler) within a quality improvement framework over seven months., Results: Quantitative results showed statistically significant adoption of tools and processes and enhancement of practice behaviors and office environmental supports. The increase in tool use was immediate and was sustained for six months after implementation. Qualitative data provided insight as to how meaningful the intervention was to the core improvement teams, especially with more complicated behaviors (eg, engaging social workers or community agencies for referrals). Barriers included lack of community resources. Findings showed unanticipated outcomes such as helping practices to become medical homes., Conclusion: Lessons learned included that practices appreciate and can adopt brief interventions that have meaningful and useful tools and process to enhance psychosocial care for children 0-3 and that do not place a burden on pediatric practice. An innovative, quality improvement strategy, intuitive to pediatricians, with a brief intervention may help prevent child maltreatment.

Objective: To describe differences in geographic, demographic, treatment, and substance use characteristics by pharmacotherapy receipt among pregnant women entering publically funded treatment for opioid use disorder (OUD) in the United States., Methods: 1996 to 2014 Treatment Episode Data Set-Admissions data from pregnant admissions with OUD, defined as reporting opioids as the primary substance of use leading to the treatment episode, were analyzed for this cross-sectional study. The proportion of all pregnant admissions with OUD who received pharmacotherapy was calculated by year and U.S. census region. Trends across time were assessed using the Cochrane-Armitage Trend test. Associations between demographic, substance use, and treatment characteristics and pharmacotherapy receipt were assessed using Chi-square tests and multivariable logistic regression., Results: The proportion of pregnant admissions where opioids were the primary substance of use increased from 16.9% to 41.6% during the study period, while the proportion of pregnant admissions with OUD who received pharmacotherapy remained relatively unchanged at around 50%. Overall, pharmacotherapy recipients were generally older and white, more likely to receive treatment in an outpatient setting, be self-referred, and report heroin as the primary substance, daily substance use, and intravenous drug use, and less likely to have a co-occurring psychiatric problem compared to those who did not receive pharmacotherapy. Regional differences in pharmacotherapy utilization exist; the South consistently had the fewest pregnant admissions with OUD receiving pharmacotherapy., Conclusion: Although the proportion of pregnant admissions to substance use treatment centers with OUD has increased since the mid-1990s, the proportion receiving pharmacotherapy has not changed. Significant variations in pharmacotherapy utilization exist by geography and demographic, substance use and treatment characteristics. Utilization of pharmacotherapy at publically funded treatment centers providing care for pregnant women with OUD should be expanded., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Contingency management (CM) is an effective intervention for reducing use of licit and illicit substances in a variety of populations. Pregnant women are a vulnerable population with much to gain from effective interventions for substance use disorders, and for whom CM interventions may be especially well-suited. We reviewed the literature on CM interventions among pregnant women with tobacco and other substance use disorders with 3 aims: (a) describe the effectiveness of CM for reducing use of tobacco and other substances during pregnancy, (b) describe the effects of CM interventions on infant outcomes, and (c) identify needs for future research on CM in pregnancy. Our search strategy revealed 27 primary studies of CM in pregnancy. CM was effective in the majority of studies targeting nicotine abstinence, and results were mixed in studies targeting illicit substances. A variety of methodologies were used within the relatively small number of studies making it difficult to identify underlying mechanisms. Also, very few studies reported maternal and infant outcomes, and significant effects of CM were only apparent when secondary analyses pooled data from multiple studies. Furthermore, there is extremely limited data on the cost effectiveness of CM interventions in pregnancy. Future research should address these 3 areas to better determine the ultimate value of CM as an efficacious treatment for pregnant women with substance use disorders. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

The increased prevalence of opioid use disorder and access to medical insurance is subsequently increasing the likelihood that medical professionals will encounter individuals with opioid use disorder. Sharp increases in opioid use disorder among women mean that obstetricians, gynecologists, and other reproductive medicine providers may be especially likely to encounter such patients. Medical professionals' understanding of treatment for opioid use disorder and their roles in their patients' treatment may increase referrals to treatment, reduce stigma, and improve the quality of medical care. Treatment for opioid use disorder falls into four overlapping domains: medication management, medical care, behavioral/mental health care, and psychosocial support. In this review, we discuss these domains with an emphasis on pregnant women and women of reproductive age. Treatment for opioid use disorder is most effective when all providers coordinate care in an informed, nonjudgmental, patient-centered approach., (Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background Parenting women with substance use disorder could potentially benefit from interventions designed to decrease stress and improve overall psychosocial health. In this study we assessed whether a mindfulness based parenting (MBP) intervention could be successful in decreasing general and parenting stress in a population of women who are in treatment for substance use disorder and who have infants or young children. Methods MBP participants (N = 59) attended a two-hour session once a week for 12 weeks. Within-group differences on stress outcome measures administered prior to the beginning of the MBP intervention and following the intervention period were investigated using mixed-effects linear regression models accounting for correlations arising from the repeated-measures. Scales assessed for pre-post change included the Perceived Stress Scale-10 (PSS) and the Parenting Stress Index-Short Form (PSI). Results General stress, as measured by the PSS, decreased significantly from baseline to post-intervention. Women with the highest baseline general stress level experienced the greatest change in total stress score. A significant change also occurred across the Parental Distress PSI subscale. Conclusions Findings from this innovative interventional study suggest that the addition of MBP within treatment programs for parenting women with substance use disorder is an effective strategy for reducing stress within this at risk population.

Opioid use disorder (OUD) among pregnant women increased substantially between 1992 and 2012 across the United States, with the greatest increases occurring in the southern states. We analyzed the 2013 Treatment Episodes Database-Admissions to determine how substances used, characteristics of treatment, and demographics of pregnant women entering treatment for opioid use disorder vary between geographical regions. Analyses were restricted to cases where women reported being pregnant at the time of admission and reported opioids as the primary substance problem leading to the treatment admission. Characteristics were compared between U.S. census regions using Chi-square tests and logistic regression with the South census region as the reference group. Compared to the South, pregnant women admitted for OUD treatment in other regions were 33-79% less likely to use benzodiazepines, twice as likely to be admitted to medication assisted treatment (MAT), 2-3 times more likely to use heroin, and up to 1.5 times more likely to inject drugs. Fewer women in the South reported having medical insurance, education beyond high school, and being married. There is a need in the southern U.S. for policies and treatment programs to target reducing concomitant opioid and benzodiazepine use, increasing access to, and utilization of, MAT, and increasing access to medical insurance., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Brief tools are needed to help physicians and parents reach consensus on body mass index (BMI) categories for children and to discuss health-improving behaviors. This study tested the Fitwits TM intervention with interactive flashcards and before and- after surveys to improve parents' perceptions of children's BMI status., Methods: We enrolled 140 parents and their 9- to 12-year-old children presenting for well child care, regardless of BMI status, scheduled with 53 Fitwits-trained physicians. The Fitwits tool guided a conversation with all parent-child dyads regarding understanding BMI, nutrition, activity, and portion sizes. A survey addressed BMI category perceptions before and after the intervention, requested 2 goal selections, and included open-ended comment areas., Results: Fifty-three percent of children were overweight or obese. The primary outcome variable was the rate of correct parental identification of their child's weight status (underweight, healthy, overweight, or obese). The survey before the intervention resulted in 50.0% correct BMI category designations. This changed to 60.6% correct perceptions after the intervention, with movement between correct overweight (34.5% to 51.7%) and obese (4.4% to 24.4%) categories. Secondary outcome variables included specific behavior change goals and the qualitative responses of parents, children, and physicians to the intervention. Parent-child dyads predominantly commented favorably and chose (75.8%) goals corresponding to Fitwits card suggestions., Conclusions: An improvement was observed in parental ability to identify the correct BMI category after the intervention during a preadolescent well child visit. Parent underrecognition of overweight/obese children was also observed. Most parent comments were appreciative of the physician interaction, Fitwits flashcards, and health improvement exchange., (© Copyright 2017 by the American Board of Family Medicine.)

Background: Pediatric patients seek timely access to subspecialty care within a complex delivery system while facing barriers: distance, economics, and clinician shortages. Aim We examined stakeholder perceptions about solutions to the access challenge. We engaged over 300 referring primary care pediatricians in the evaluation of Access Clinics at an academic children's hospital., Methods: Using an anonymous online survey, we asked pediatricians about their and their patients' experiences and analyzed factors that may influence referrals. Findings Referring pediatricians reported satisfaction; they provided feedback about their patients' experiences, physician communication, and referral influences. Distance from the Access Clinic does not correlate with differences in referral volume; living in areas with higher child populations and higher median income is associated with more referrals. Referring pediatricians have strong opinions about referrals, are attuned to patient experiences, and desire bi-directional communication. Multiple factors influence referral to and acceptance of Access Clinics, but external influences have less impact than expected., Competing Interests: & Financial Disclosure The authors have no relevant financial relationships to disclose. The authors have no conflicts of interest to disclose.

Objective: The incidence of neonatal abstinence syndrome (NAS), a drug withdraw syndrome mainly associated with intrauterine opioid exposure, has increased considerably in the United States since 2000. Nonpharmacological options, including breastfeeding, may be effective at improving outcomes in this population. The objective of this population-based study was to examine the association between breastfeeding and length of hospital stay among infants diagnosed with NAS., Methods: This was a retrospective cohort study of singleton in-hospital births to resident mothers in Pennsylvania. Hospital discharge data from births occurring between 2012 through 2014 were linked with corresponding birth certificate data. International Classification of Diseases, Ninth Revision, Clinical Modification discharge diagnosis codes were used to identify NAS neonates (N = 3,725). Breastfeeding at discharge was used to determine breastfeeding status. Infant and maternal characteristics were compared by breastfeeding status and the association between breastfeeding and infant length of hospitalization was assessed., Results: Less than one-half of infants diagnosed with NAS were breastfed at discharge. Significant differences in infant birth weight and gestational age, and maternal education, marital status, prenatal care, smoking, and insurance status were found by breastfeeding status. A significant inverse relationship existed between breastfeeding and hospital length of stay for infants diagnosed with NAS. Specifically, length of hospitalization was reduced by 9.4% in the breastfed group compared to the nonbreastfed group., Conclusion: Breastfeeding may be beneficial for infants diagnosed with NAS by shortening the length of hospital stay. Future prospective studies are warranted to further examine the benefits of breastfeeding and other nonpharmaceutical interventions in NAS populations.

African American women have higher rates of preterm birth (PTB) than women from other racial or ethnic backgrounds. We explored the possibility that African American women experience higher anxiety/lower optimism levels, leading to excess inflammation, a possible pathway leading to PTB. In a cohort of 434 nulliparous women (African American, n = 119; Caucasian, n = 315), standardized measures of anxiety and optimism were completed at 20 weeks' gestation. C-reactive protein (CRP) was measured in serum collected at the same time, and interleukin-6 (IL-6) was additionally measured in African American women. African American women tended to have higher rates of anxiety (>75th percentile) compared to Caucasian women (27.3 vs. 19.2%, p = 0.08), but rates of low optimism (<25th percentile) did not vary by race. Contrary to our hypothesis, higher concentrations of CRP among African American women were associated with lower risk of anxiety in the highest quartile, adjusted for covariates (OR 0.65, 95% CI 0.44, 0.98). Low optimism in African American women was also associated with lower IL-6, but results were only marginally significant (OR 0.43, 95% CI 0.17, 1.10). CRP, anxiety, and optimism were not correlated among Caucasian women. African American women with high anxiety or low optimism had lower concentrations of pro-inflammatory markers at mid-gestation compared to those without these characteristics. Our results suggest that chronic anxiety among African American women may contribute to intractable race disparities in pregnancy outcomes via an impaired inflammatory response.

Objective: To describe ethnic disparities in parental confidence managing child weight-related behaviors., Methods: This was a cross-sectional survey of 59 parents of children with obesity between 4 and 7 years of age presenting to a tertiary care pediatric weight management clinic. Parents completed a validated measure assessing their confidence managing their child's weight-related behaviors (parent confidence score). Student's t-tests and linear regression analyses were used to determine parent and child characteristics associated with parent confidence score., Results: Families were ethnically diverse with half being of Hispanic ethnicity. Mean parent confidence score was 159 (SD 66) with 71% of parents with parent confidence scores below the clinical cut-off for the measure. Parent confidence score was lower among Hispanic (mean 133, SD 67) compared to non-Hispanic parents (mean 184, SD 55, p < 0.01). Parent confidence score was most strongly associated with parental ethnicity (β = -0.39, p = 0.002, adjusted R(2) = 0.14)., Conclusion: Parental confidence managing weight-related behaviors was low among parents of young obese children, especially those of Hispanic ethnicity., Practice Implications: This study highlights the need to assess parental confidence in managing weight-related behaviors as part of pediatric obesity care and to provide counseling to improve parental management of weight-related behaviors in a culturally-appropriate manner., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: To explore social network members' role in educating African American adolescents about sexual health issues., Design: We conducted 21 focus groups with urban African American mothers (n=51), fathers (n=18), sons (n=20), and daughters (n=36) from Allegheny County, Pennsylvania, USA, between December 2007 and March 2008. At least one biological parent (or legal guardian) and one adolescent aged 15-17 years from each family participated. Group conversations were audio-recorded, transcribed, and analyzed using directive content analysis and the constant comparison method. Two coders independently read each transcript to identify emergent themes., Results: A broad range of people were reportedly involved in the education process. Older siblings, extended family, and peers were most commonly cited. However, unrelated adults were also described as playing important roles. Unrelated adults included the friends of an adolescent's parents and the parents of an adolescent's friends or romantic partners. Social network members were said to address three main issues: the facts about sex and sexuality, the social aspects of sexuality (e.g., appropriate dating behaviors, choosing dating partners), and promotion of family values. When educating adolescents about sex, social network members were described as playing eight functional roles, including that of a teacher, guide, challenger, confidant, shelterer, supervisor-chaperone, role model, and provider of access to reproductive health services. These roles were not mutually exclusive, meaning that social network members often assumed different roles depending on the situation. The influence of individuals who were not an adolescent's parent was highly dependent on adolescents' relationship with their parents or on their parents' comfort dealing with sexual issues., Conclusions: African American adolescents' social networks were described by parents and adolescents as dense, complex, and routinely involved in educating adolescents about sex.

A novel use of genograms in primary care practice is to identify processes and relationships among physicians and staff prior to implementing practice change. The authors hypothesized that the genogram would inform researchers and practice staff, participating in a child maltreatment prevention study, how practice members function in a practice. They describe the use of genograms and show how the genogram results are associated with intervention uptake. Researchers constructed genograms, collected baseline surveys, and conducted postintervention interviews with physicians. Data were analyzed to determine processes associated with intervention uptake. While survey results supported the relationships and conflicts observed in the genograms, the genogram provided more multilevel information that reflected practices' abilities to implement change. By providing a snapshot of the relationship and organizational dynamics within a practice, genograms can assess culture for practice change. Genograms describe organizational dynamics and are useful tools to use prior to initiating new programs.

Background: Physician feelings of ineffectiveness and family-related barriers hamper childhood obesity discussions. Physicians desire appealing, time-efficient tools to frame and sensitively address obesity, body mass index, physical activity, nutrition, and portion size. Our university design-led coalition codeveloped tools and games for this purpose., Methods: In this feasibility study, we evaluated physician-level counseling of 9- to 12-year-old children and their parents/caretakers using Fitwits MD (Carnegie Mellon University School of Design, Pittsburgh, PA), a brief, structured intervention with flashcards and take-home games. Residency-based physicians in three low- to mid-level socioeconomic urban offices provided self-report data over 8 months through surveys, comment cards, and interviews., Results: We recruited 33 physicians and 93 preadolescents and families. Child-centered key messages resulted in 7-minute conversations, on average. For those physicians who used Fitwits MD, 96% felt improved comfort and competence and 78% noted barrier reduction., Conclusions: Fitwits MD improved residency-based physician self-efficacy and emphasized important health education topics regarding office-based childhood obesity discussions with preadolescents and parents/caretakers.

Psychosocial factors such as anxiety or optimism may be related to the risk of adverse pregnancy outcomes, but the evidence is conflicting. We investigated the relation between maternal anxiety, optimism, gestational age and infant birth weight in a cohort of 667 nulliparous women from the Prenatal Exposures and Preeclampsia Prevention study, Pittsburgh PA. Women completed the Spielberger Trait Anxiety Inventory and the Life Orientation Test at 18 weeks gestation. Linear and logistic regression models assessed the relation of anxiety and optimism to gestational age, birth weight centile, preterm delivery (<37 weeks) or small for gestational age (<10th percentile) births. After adjustment for age, race, preeclampsia, and smoking, higher anxiety was associated with decreasing gestational age (-1.6 days per SD increase in anxiety score, P = 0.06). This relationship was modified by maternal race (P < 0.01 for interaction). Among African American women, each SD increase in anxiety was associated with gestations that were, on average, 3.7 days shorter (P = 0.03). African American women with anxiety in the highest quartile had gestations that were 8.2 days shorter, and they had increased risk for preterm birth after excluding cases of preeclampsia (OR 1.69, 95% CI 1.08, 2.64). There was no association between anxiety and gestational age among White women. There was also no relation between anxiety, optimism and birth weight centile. Trait anxiety was associated with a reduction in gestational age and increased risk for preterm birth among African American women. Interventions that reduce anxiety among African American pregnant women may improve pregnancy outcomes.

Background: Underserved populations are underrepresented in public health initiatives such as tobacco control and in cancer clinical trials. Community involvement is crucial to interventions aimed at reducing health disparities, and local health departments increasingly are called upon to provide both leadership and funding. The Tacoma Pierce County Health Department (TPCHD), in conjunction with 13 key community-based organizations and healthcare systems, formed the Cross Cultural Collaborative of Pierce County (CCC) that successfully employs needs-assessment and evaluation techniques to identify community health initiatives., Methods: Community leaders from six underserved populations of the CCC were trained in needs-assessments techniques. Assessments measured effectiveness of the collaborative process and community health initiatives by using key informant (n = 18) and group interviews (n = 3)., Results: The CCC, facilitated by its partnership with the TPCHD, built capacity and competence across community groups to successfully obtain two funded public health initiatives for six priority populations. Members expressed overall satisfaction with the training, organizational structure, and leadership. The CCC's diversity, cultural competency, and sharing of resources were viewed both as a strength and a decision-making challenge., Conclusion: Public health department leadership, collaboration, and evidence-based assessment and evaluation were key to demonstrating effectiveness of the interventions, ensuring the CCC's sustainability.

Despite reductions in perinatal HIV transmission, cases continue to occur. To determine factors associated with zidovudine (ZDV) receipt among HIV-infected pregnant women we merged three data sets for women in New Jersey in 1995-1997, identifying 395 HIV-infected pregnant women. Half received two arms of ZDV prophylaxis. Attendance at five or more prenatal visits was the strongest independent factor related to ZDV receipt (OR 6.37, 95% CI 3.84, 10.57). Half (49.0%) had limited prenatal care. AIDS diagnosis, race/ethnicity, and drug use were also independently related to ZDV receipt. Post hoc analysis revealed that being unmarried, Black, multiparous, having no insurance, and illegal drug use were associated with limited prenatal care. Although the U.S. has seen reductions in HIV perinatal transmission, our research showed that HIV-infected women who did not get prenatal care were less likely to receive two arms of ZDV prophylaxis. A wide public health net that brings all women into care is necessary to reduce perinatal transmission further.

Background: Behavioral, developmental, and psychosocial problems ("new morbidities") significantly affect the well-being of children ages 0-3 years. Practices generally fail to deliver consistent anticipatory guidance or counseling to parents. A multifaceted intervention was designed to increase the capacity of three very different practice types to adopt and implement Practicing Safety, a child abuse and neglect prevention program., Methods: Using a feasibility intervention study, a combination of organizational change approaches, including complexity science principles--self-organization, emergence, and co-evolution--were tested. The multimethod assessment process (MAP) was employed to understand the unique characteristics of each practice that could impede or promote innovation. Findings guided a facilitated, team-based change intervention, the Reflective Adaptive Process (RAP) to restructure psychosocial care., Findings: Each practice demonstrated fundamental changes in decision making, developmental assessment, and parent education processes. Practicing Safety tools were adopted and incorporated into daily routines. RAP team members exhibited new patterns of communication and relationships that supported organizationwide preventive service innovations., Discussion: The MAP and RAP interventions enabled study practices to integrate novel methods for prevention of child abuse and neglect into daily routines.

Physicians play an important role in smoking cessation, especially discussing medications. This study evaluates physician characteristics associated with higher rates of discussion of smoking cessation medications. 336 primary-care physicians in New Jersey completed a cross-sectional, self-administered, mail survey including physician demographics, practice type, previous training and confidence in treating tobacco dependence, awareness of guidelines, and perceived effectiveness of treatments. Two-thirds of respondents felt confident in using cessation medications despite only 24% having previous training and only 13% having read or implemented practice guidelines. After controlling for other variables, female physicians were more likely to discuss medications compared with males (adjusted odds ratio(AOR) 2.2; 95% confidence interval(CI) 1.0-4.6); physicians who were confident were more likely to discuss (AOR 3.0;95% CI 1.7-5.3); and physicians in private practices (solo, group, or multispecialty) were more likely to discuss than those employed by an agency (hospital, state, or federal) (AOR 3.1;95% CI 1.4-6.8). Most physicians in this sample reported routinely discussing cessation medications, with female physicians, those feeling confident, and those in private practices doing so more frequently. Considering limited resources and opportunities to access physicians, interventions to increase discussion of effective cessation treatments could be targeted to specific physician groups.

Background: Historically, achieving a high response rate on physician surveys has been a challenging task. Given such concerns, understanding research strategies that facilitate adequate response rates is important. Primary care physician responses to a mail survey on smoking cessation are summarized by physician specialty and timing of incentive., Methods: A stratified random-sample design, stratified by patient populations-adults, adolescents, and pregnant women-was used. The sampling frame included New Jersey internists, general practitioners, family physicians, pediatricians, and obstetrician-gynecologists. A total of 2100 physicians, 700 physicians from each patient strata, were sampled and mailed a smoking-cessation survey in summer 2002. The sample was randomized by incentive timing: Half received the incentive (i.e., 25 dollars gift card) with the first survey mailing, and half received the incentive on receipt of their completed survey., Results: The promised-incentive group achieved a significantly lower response rate (56%) compared with the up-front-incentive group (71.5%). Response rates by medical specialty varied overall and within incentive groups. The difference between the incentive groups was greatest among obstetrician-gynecologists (i.e., 20.2 percentage points) and was least among pediatricians (i.e., 5.8 percentage points)., Conclusions: Physician response rates to mail surveys are greatly improved, especially among certain medical specialties, by using up-front incentives.