The Impact of Social Vulnerability on Substance Use Detection Practices in Pregnancy.

This study aimed to synthesize current literature regarding the impact of social vulnerability on pregnancy-related substance use detection in the United States and highlight disparities in substance use detection practices. Clinicaltrials.gov, Google Scholar, PubMed (includes MEDLINE), and Cochrane Library databases were searched using the following Medical Subject Headings (MeSH): (["pregnancy" or "prenatal"] AND ["substance use screening" or "urine toxicology testing" or "toxicology testing" or "urine drug screening" or "CRAFFT" or "4P's" or "4P's Plus" or "NIDA Quick Screen" or "DAST-10" or "SURP-P" or "WIDUS"], AND ("bias" or "disparities" or "social vulnerability"]). The search included systematic reviews, prospective and retrospective studies, randomized controlled trials, case studies, and qualitative and quantitative research from January 2014 through November 2023. Selected literature was limited to studies published in English, which included a study population of either pregnant individuals or pregnancy health care providers in the United States, and that were focused on inequities in pregnancy substance use detection. Using Covidence, three authors screened abstracts, and two screened full articles for inclusion. The included studies were evaluated for quality of evidence using the mixed methods appraisal tool. The search yielded 4,188 manuscripts; 37 were eligible for full review. A total of 18 manuscripts were included based on the relevancy of the topic. The most common social vulnerability domain identified was minority status (17/18), followed by socioeconomic status (11/18), household characteristics (8/18), and housing type (1/18). Social vulnerability plays a role in substance use detection among pregnant individuals. Most notably, race and ethnicity, age, and public insurance lead to increased rates of detection, though most individual factors need to be studied in greater depth. This study was registered with PROSPERO (PROSPERO ID CRD42022352598), the International Prospective Register of Systematic Reviews. KEY POINTS: · Socially vulnerable pregnant individuals are more likely to receive substance use screening or urine toxicology testing.. · Race, ethnicity, age, and insurance influence substance use detection disparities.. · More research is needed to understand how other characteristics influence disparities in substance use detection..

Redesigning the First Prenatal Visit: A Quality Improvement Initiative.

BACKGROUND/PURPOSE: In an era of rising maternal mortality, a thorough first prenatal visit is essential; however, in our clinic we confirmed that many important topics were not being addressed. To rectify this problem, we redesigned the first prenatal visit to improve the coverage of topics, collect social determinants of health, increase patient access, and maintain patient satisfaction. METHODS: We designed a quality improvement project to improve the first prenatal visit in a faculty obstetrics and gynecology clinic. To assess effectiveness, data before and after the implementation were compared. The intervention divided the first prenatal visit into two patient encounters: a nurse-led telemedicine visit and an in-person visit with an obstetric clinician. RESULTS: The median percentage of topics covered in the first prenatal visit increased from 70.0% to 95.6%, and improvements were observed for all key themes ( p < .001). Social determinants of health was routinely collected postintervention (98.8%). A reduction in no-shows (9.9%-4.2%) improved patient access for all patients. Patient satisfaction for the first prenatal visit remained unchanged ( p = .370). CONCLUSIONS: Significant improvements in addressing important topics at the first prenatal visit are achievable by separating one prenatal visit into two visits while increasing patient access and maintaining high patient satisfaction.

Using the Technology Acceptance Model to Develop StartSmart: mHealth for Screening, Brief Intervention, and Referral for Risk and Protective Factors in Pregnancy.

INTRODUCTION: Technology decision support with tailored patient education has the potential to improve maternal and child health outcomes. The purpose of this study was to develop StartSmart, a mobile health (mHealth) intervention to support evidence-based prenatal screening, brief intervention, and referral to treatment for risk and protective factors in pregnancy. METHODS: StartSmart was developed using Davis' Technology Acceptance Model with end users engaged in the technology development from initial concept to clinical testing. The prototype was developed based upon the current guidelines, focus group findings, and consultation with patient and provider experts. The prototype was then alpha tested by clinicians and patients. Clinicians were asked to give feedback on the screening questions, treatment, brief motivational interviewing, referral algorithms, and the individualized education materials. Clinicians were asked about the feasibility of using the materials to provide brief intervention or referral to treatment. Patients were interviewed using the think aloud technique, a cognitive engineering method used to inform the design of mHealth interventions. Interview questions were guided by the Screening, Brief Intervention, Referral to Treatment theory and attention to usefulness and usability. RESULTS: Expert clinicians provided guidance on the screening instruments, resources, and practice guidelines. Clinicians suggested identifying specific prenatal visits for the screening (first prenatal visit, 28-week visit, and 36-week visit). Patients reported that the tablet-based screening was useful to promote adherence to guidelines and provided suggestions for improvement including more information on the diabetic diet and more resources for diabetes. During alpha testing, participants commented on navigability and usability. Patients reported favorable responses about question wording and ease of use. DISCUSSION: Clinicians reported the use of mHealth to screen and counsel pregnant patients on risk and protective factors facilitated their ability to provide comprehensive care.

Reliability and Validity of HeartSmartKids: A Survey of Cardiovascular Risk Factors in Children.

INTRODUCTION: Reliable and valid instruments to measure counseling effectiveness related to eating, activity, and inactivity are lacking. HeartSmartKids (HSK; HeartSmartKids, LLC, Boulder, Colorado) is a bilingual decision-support technology that can be used to assess and counsel families on cardiovascular risk factors in children. The purpose of this study was to establish preliminary test-retest reliability and convergent validity of HSK questions relative to a previously validated questionnaire, HABITS. METHOD: Data were collected from children (ages 9-14 years) during an intervention study. A multitrait/multimethod correlation matrix framework was used to examine the test-retest reliability (n = 35) and convergent validity (n = 103) of HSK relative to HABITS. RESULTS: HSK had moderate/strong test-retest reliability and good convergent validity between HSK and HABITS. DISCUSSION: This study provides preliminary test-retest reliability and convergent validity of a useful clinical tool that can be used to quickly assess children's nutrition (e.g., fruit/vegetable consumption, snacks, sugar-sweetened beverages, breakfast) and activity habits to guide behavior change counseling. Additional work should be done validating HSK with objective measures.

Technology to Support Motivational Interviewing.

PURPOSE: This paper reports the findings of motivational interviewing (MI) training with and without technology support on school-based health center (SBHC) providers' satisfaction with MI training, providers' self-report of behavioral counseling related to childhood overweight/obesity, and parents' perception of care after training. DESIGN AND METHODS: The effects of training and technology on MI is part of a larger comparative effectiveness, cluster randomized trial. Twenty-four SBHCs in six states received virtual training on MI. Half the sites received HeartSmartKids™, a bilingual (English/Spanish), decision-support technology. The technology generated tailored patient education materials. Standard growth charts were plotted and health risks were highlighted to support MI counseling. The results of the MI training included provider satisfaction with MI training and parent assessment of the components of MI in their child's care. Providers and parents were surveyed at baseline, after training, and six months after training. RESULTS: Providers were satisfied with training and reported improvements in counseling proficiency (p<0.0007) and psychological/emotional assessment (p=0.0004) after training. Parents in the technology group reported significant improvement in provider support for healthy eating (p=0.04). CONCLUSION: Virtual training has the potential of preparing providers to use MI to address childhood obesity. Technology improved parent support for healthy eating. Future research should evaluate the impact of technology to support MI on patient outcomes. PRACTICE IMPLICATIONS: Childhood obesity guidelines emphasize that MI should be used to promote healthy weight in children. Training providers on MI may help more providers incorporate obesity guidelines in their practice.

A Pilot Intervention Designed to Address Behavioral Factors That Place Overweight/Obese Young Children at Risk for Later-Life Obesity.

The purpose of this pilot randomized controlled trial (RCT) was to intervene with parents of overweight/obese 4- to 8-year-old children to improve child internalizing and externalizing behaviors. Parent-child dyads ( N = 60) were randomly assigned to treatment or comparison conditions. Parents attended four intervention sessions at their child's primary health care office over 3 months. Child behaviors were assessed at 0, 3, 6, and 12 months post intervention. Parental beliefs in their skills/abilities increased in the experimental group parents, but there was no statistical difference between groups at any time. Child externalizing behaviors significantly decreased from baseline to postintervention for both groups ( F = 3.26, p = .020). Post hoc model testing suggests that this change was more pronounced in the intervention group ( F = 0.56, p = .692). Child somatic symptoms significantly decreased over time ( F = 4.55, p = .004), and there were group differences in child depressive behaviors ( F = 6.19, p = .020). These findings suggest that a parent-focused intervention program demonstrated positive preliminary effects on children's behaviors.

Early Initiation of Newborn Individualized Developmental Care and Assessment Program (NIDCAP) Reduces Length of Stay: A Quality Improvement Project.

Infants born at ≤32weeks gestation are at risk of developmental delays. Review of the literature indicates NIDCAP improves parental satisfaction, minimizes developmental delays, and decreases length of stay, thus reducing cost of hospitalization. Half (50.6%) of the infants admitted to this 84-bed Level IV Neonatal Intensive Care Unit (NICU) with a gestational age of ≤32weeks were referred for NIDCAP. The specific aims of this quality improvement project were to 1) compare the age at discharge for infants meeting inclusion criteria enrolled in NIDCAP with the age at discharge for those eligible infants not enrolled in NIDCAP; and 2) investigate the timing of initiation of NIDCAP (e.g., within six days of admission) on age at discharge. During the 12month period of data collection, infants enrolled in NIDCAP (M=27.85weeks, SD=1.86) were 2.02weeks younger than those not enrolled in NIDCAP (M=29.87weeks, SD=2.49), and were 2.32weeks older at discharge (M=38.28weeks, SD=5.10) than those not enrolled in NIDCAP (M=35.96weeks, SD=5.60). Infants who enrolled within 6days of admission were discharged an average of 25days sooner (p=0.055), and at a younger post-menstrual age (by 3.33weeks on average), than those enrolled later (p=0.027).

Comparing Weight-for-Length Status of Young Children in Two Infant Feeding Programs.

Objectives A cross-sectional study comparing weight-for-length status of children 6-24 months old who participated in Nurse-Family Partnership (NFP) or Special Supplemental Program for Women, Infants, and Children (WIC). Methods Secondary analysis of NFP (n = 44,980) and WIC (n = 31,294) national datasets was conducted to evaluate infant and toddler growth trajectories. Weight-for-length status was calculated at 6, 12, 18, and 24 months based on World Health Organization criteria. Demographics and breastfeeding rates were also evaluated. Binary logistic regression was used to calculate odds ratios for high weight-for-length (≥97.7 percentile) at each time point. Results At 6 months, approximately 10 % of WIC and NFP children were classified as high weight-for-length. High weight-for-length rates increased for both groups similarly until 24 months. At 24 months, NFP children had significantly lower rates of excess weight (P = 0.03) than WIC children, 15.5 and 17.5 % respectively. At all time points, non-Hispanic white children had lower rates of high-weight for length than Hispanic and non-Hispanic black children. NFP infants were also found to have higher rates of ever being breastfed than WIC infants (P < 0.0001). Conclusions for Practice Infant and toddler populations served by NFP or WIC were found to be at increased risk for high weight-for-length. This study found NFP participation was associated with a small, but significant, protective impact on weight-for-length status at 24 months. Continued efforts need to be made in addressing weight-related racial/ethnic and socioeconomic disparities during early childhood.

Virtual obesity collaborative with and without decision-support technology.

OBJECTIVE: The purpose of this study was to evaluate school-based health center (SHBC) provider adherence to guidelines for identification and assessment of childhood obesity after participation in a virtual Health Disparities Learning Collaborative with and without HeartSmartKids™, decision-support technology with tailored patient education. DESIGN AND SETTING: A cluster randomized comparative effectiveness trial was conducted with 24 SBHCs from six states. PARTICIPANTS: The sample consisted of 33 SBHC providers and review of medical charts at three time points. Chart data were collected at baseline (n = 850), after training (n = 691) and 6 months after training (n = 612). MAIN OUTCOME MEASURES: Charts from a random sample of youth 5-12 years making well-child visits were examined for the documentation of: BMI percentile, accurate weight diagnosis based upon BMI percentile, blood pressure percentile, and ordering appropriate laboratory assessment of obese youth ≥10 years old. RESULTS: Percentage of overweight/obese children in this study was 40.4-47.2%. For both the HeartSmartKids™ and non-HeartSmartKids™ groups, provider adherence significantly improved after training for BMI percentile and blood pressure percentile documentation, as well as correct diagnosis for overweight and obese. Implementation of the HeartSmartKids™ was variable at the technology sites and differences in identification and assessment were not found between groups. CONCLUSION: The virtual collaborative approach to quality improvement resulted in improved adherence to guidelines for identification and assessment of overweight/obese children. The impact of the training with and without HeartSmartKids™ on patient outcomes needs to be evaluated. Coaching on implementation of technology needs to be included in future work.

Characterization of Childhood Obesity and Behavioral Factors.

INTRODUCTION: Childhood obesity is a major public health threat in the United States. Recent data indicate that 34.2% of children ages 6 to 11 years are overweight or obese. The purpose of this study is to describe childhood obesity levels and identify risk behaviors in two school-based health centers in Michigan, one urban and one rural. METHODS: This study is a secondary data analysis from a multicenter comparative effectiveness trial. Multiple logistic regression was used to examine behavioral factors associated with overweight/obesity in children. RESULTS: In this sample (n = 105), 41.9% were obese and 16.2% were overweight. The duration of sleep per night (p = .04) and the frequency of eating breakfast (p = .04) were significant predictors of being overweight/obese. DISCUSSION: Health care providers in school-based health centers must be comfortable assessing, preventing, and treating childhood obesity in this high-risk group of patients. Interventions should encourage children to eat breakfast daily and to get adequate sleep.

Identifying patterns of obesity risk behavior to improve pediatric primary care.

PURPOSE: To develop profiles of obesity risk behaviors for children and adolescents. DESIGN AND METHODS: Risk assessments were obtained from patients (n = 971) at a school-based health center. Latent class analysis was used to create subgroups based on seven indicators measuring diet, activity, and screen time. RESULTS: Four classes emerged, with 44% classified as the "Healthiest," 8% as the "Least Healthy," 37% as "Mixed Diet/Low Activity/Low Screen Time," and 11% as "Mixed Diet/High Activity/High Screen Time." Several demographic predictors distinguished the classes. PRACTICE IMPLICATIONS: Obesity risk factor profiles may help providers identify strengths and risks, tailor counseling, and plan interventions with families.

A Virtual Childhood Obesity Collaborative: Satisfaction With Online Continuing Education.

INTRODUCTION: This descriptive study evaluated school-based health center (SBHC) providers' satisfaction with Web-based continuing education as part of a virtual childhood obesity intervention. METHOD: Thirty-six participants from 24 SBHCs in six states participated in the training modules. Modules were divided into four learning sessions, with a total of 17 training modules. Participants completed satisfaction surveys after each module, as well as an overall survey at the end of the training. Questions were rated on a 4-point Likert scale (4 = strongly agree, 3 = agree, 2 = disagree, 1 = strongly disagree). RESULTS: Participation in the first two learning sessions was higher than the last two. Provider satisfaction of training modules by question type and content area was quite high (µ = 3.66-3.33). Overall satisfaction means ranged from 3.76 to 3.24. Many providers also reported plans to make changes in their practice after completing the training. DISCUSSION: This study demonstrated that a virtual childhood obesity collaborative is an acceptable delivery method for continuing education.

Clinician adherence to childhood overweight and obesity recommendations by race/ethnicity of the child.

PURPOSE: This study describes school-based health center (SBHC) providers' adherence to obesity guidelines. DESIGN AND METHODS: Providers (n = 28) were from SBHCs in six states serving children 5-12 years of age. A random sample of well-child charts (n = 850) were audited for body mass index percentage, blood pressure percentage, overweight/obesity diagnosis, and laboratory assessment. RESULTS: Body mass index percentage was documented on 73% of charts and blood pressure percentage on 30.5%. Providers accurately diagnosed 40% overweight and 49.3% obese children. Laboratory guidelines were followed in 80.4% of cases. Assessments differed by child's race/ethnicity (p < .05), with most criteria having higher adherence in minority youth. PRACTICE IMPLICATIONS: There is a need for increased accuracy in how SBHC providers screen overweight/obese children.

School-based health center providers' treatment of overweight children.

This descriptive study was to determine self-reported treatment practices of school-based health center (SBHC) providers when caring for overweight/obese children. Providers (N=33) from SBHCs in 6 states (AZ, CO, NM, MI, NY, and NC) completed a baseline survey before being trained on obesity recommendations. SBHC providers reported patient/parent barriers to be more significant to treatment than clinician/setting barriers (p<0.0001). Most providers (97%) indicated childhood overweight needs treatment, yet only 36% said they initiate treatment in children who do not want to control their weight. SBHC providers also did not commonly refer overweight/obese children to specialists.

Identification and assessment of childhood obesity by school-based health center providers.

INTRODUCTION: School-based health centers (SBHCs) serve many overweight/obese children, yet little is known about provider adherence to obesity guidelines. The purpose of this descriptive study was to evaluate obesity care assessment practices of SBHC providers prior to completing training on obesity guidelines. METHOD: Providers (n = 33) from SBHCs in six states (AZ, CO, NM, MI, NY, and NC) completed The International Life Science Institute Research Foundation Assessment of Overweight in Children and Adolescents Survey. RESULTS: Most providers reported using body mass index percentile (93.9%) to assess weight. In caring for overweight/obese children, providers reported screening for hypertension 100% of the time and cardiovascular disease 93.9% of the time, and approximately two thirds reported requesting total cholesterol and lipid profile laboratory assessments. Some assessment guidelines were not routinely followed. DISCUSSION: SBHCs serve a high-risk population, and providers in this study may benefit from additional training on assessment guidelines and quality improvement processes to improve adherence to current guidelines.

A methodological quality synthesis of systematic reviews on computer-mediated continuing education for healthcare providers.

BACKGROUND: Healthcare providers use continuing education (CE) to meet professional development requirements and to ensure optimal patient care. There has been a dramatic increase in computer-mediated CE (CMCE) programs. AIMS: To synthesize the literature regarding the current state of the science on the efficacy of CMCE for healthcare professionals, particularly as it relates to provider learning and patient outcomes. Specifically, this review assesses the methodological quality of existing systematic reviews and meta-analyses. METHODS: A literature search was conducted using Cochrane Library, PubMed, and CINAHL. Review articles evaluating the efficacy of CMCE for healthcare providers were included. Publications were searched between 2002 and 2013 and limited to those printed in English. An objective measurement tool, AMSTAR, was used to assess the methodological quality of each review. AMSTAR is an 11-item instrument, in which individual criteria were evaluated and a composite score of all 11 components was determined for each review. Outcomes of each review were also categorized based on Kirkpatrick's levels for summative evaluation: (i) Learner satisfaction, (ii) Learning outcomes, (iii) Performance improvement, (iv) Patient/health outcomes. RESULTS: Starting with 231 articles, 11 met the inclusion criteria for this evaluation. AMSTAR quality scores of the reviews ranged from 7 to 11, with 11 indicating the strongest quality. Although weak research design of many studies and heterogeneous topics covered make summative evaluations difficult, there were some common themes covered in the articles reviewed. Healthcare providers were largely satisfied with using CMCE programs. Overall, the studies comparing CMCE to traditional CE methods found the impact on learning outcomes to be comparable, with neither method necessarily superior. Additionally, all reviews lacked evaluation of practice outcomes. LINKING EVIDENCE TO ACTION: While results of this review show promise for CMCE, further evaluation and more rigorously conducted research is necessary. Particular focus is needed to determine the effects of CMCE on health outcomes.

Cultivar choice provides options for local production of organic and conventionally produced tomatoes with higher quality and antioxidant content.

BACKGROUND: Tomatoes (Solanum lycopersicum L.) are widely consumed and well known for their health benefits, many of which have been associated with the high levels of antioxidants present in tomatoes. With a growing interest in local and organic foods, it would be helpful to determine whether farmers could naturally improve the quality and antioxidant content of tomatoes for sale in local markets. This study evaluated antioxidant properties, quality attributes, and yield for 10 tomato cultivars grown for 2 years using certified organic and conventional practices. RESULTS: Cultivar and year effects impacted (P < 0.05) all tests conducted, while growing method influenced (P < 0.05) yield, soluble solids content, ascorbic acid, and antioxidant radical scavenging capacity. Even when accounting for year-to-year variability, cultivars in the highest groups had 1.35- to 1.67-fold higher antioxidant levels than cultivars in the lowest groups. 'New Girl', 'Jet Star', 'Fantastic', and 'First Lady' were always in the highest groups, while 'Roma' and 'Early Girl' consistently had the lowest antioxidant content. CONCLUSION: Compared to production practices and environmental effects of years that are generally beyond the control of small-scale producers, choice of cultivar provides the simplest and most effective means of increasing antioxidant properties. Knowledge of tomato cultivars with naturally higher antioxidant levels could assist smaller-scale producers to grow fruit that may provide a competitive advantage and the opportunity to capitalize on the increasing popularity of locally grown, high-quality fresh produce.