Optimizing Postpartum Care in Rural Communities: Insights from Women in Arizona and Implications for Policy.

OBJECTIVES: Optimal postpartum care promotes healthcare utilization and outcomes. This qualitative study investigated the experiences and perceived needs for postpartum care among women in rural communities in Arizona, United States. METHODS: We conducted in-depth interviews with thirty childbearing women and analyzed the transcripts using reflexive thematic analysis to gauge their experiences, needs, and factors affecting postpartum healthcare utilization. RESULTS: Experiences during childbirth and multiple structural factors, including transportation, childcare services, financial constraints, and social support, played crucial roles in postpartum care utilization for childbearing people in rural communities. Access to comprehensive health information and community-level support systems were perceived as critical for optimizing postpartum care and utilization. CONCLUSIONS FOR PRACTICE: This study provides valuable insights for policymakers, healthcare providers, and community stakeholders in enhancing postpartum care services for individuals in rural communities in the United States.

Supportive Relationships Mitigate the Effect of Cumulative Exposure to Adverse Childhood Experiences on Depression, Anxiety, Stress, and Suicide Considerations-The Arizona Youth Risk Behavior Survey.

Declining adolescent mental health is a significant public health concern during the COVID-19 pandemic. Social distancing and stay-at-home orders have led to missed social connections with peers and adults outside households, and this has increased the risk of mental health problems in children and adolescents, particularly those with adverse childhood experiences (ACEs). Studies have shown that strong interpersonal support improves adolescent mental health. We examined the association between ACEs and poor mental health (including stress, anxiety, and depression) and how the presence of interpersonal support from caring adults and friends and school connectedness can mitigate this relationship among adolescents in Arizona. This study analyzed data from the 2021 Arizona Youth Risk Behavior Survey (YRBS; n = 1181), a population-based survey conducted biennially across the United States. The Arizona sample included high school students in grades 9-12 who were enrolled in public and charter schools. This study revealed that nearly three of four adolescents experienced an ACE, and one of five experienced ≥4 ACEs. Compared with adolescents who experienced zero ACEs, those with ≥4 ACEs experienced less interpersonal support from caring adults, friends, and school and more frequently reported poor mental health and suicidal thoughts. However, adolescents with interpersonal support consistently reported lower rates of mental health issues, even with exposure to multiple ACEs. Post-pandemic programs to improve social relationships with adults, peers, and schools are critical, especially for adolescents with multiple adversities.

Individual and community-level risk factors for maternal morbidity and mortality among Native American women in the USA: protocol for systematic review.

INTRODUCTION: Incidents of maternal morbidity and mortality (MMM) continue to rise in the USA. Significant racial and ethnic health inequities exist, with Native American (NA) women being three to four times more likely to die than white, non-Hispanic women, and three to five times more likely to experience an incident of severe maternal morbidity. Few studies have identified individual and community-level risk factors of MMM experienced by NA women. Therefore, this systematic review will identify said risk factors of MMM experienced by NA women in the USA. METHODS AND ANALYSIS: This systematic review will be conducted according to the Cochrane Handbook for Systematic Reviews, and the findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). The search strategy will include searches from electronic databases: PUBMED, EMBASE, CINAHL and SCOPUS, from 1 January 2012 to 10 October 2022. The search strategy will include terms related to the search concepts: 'maternal', 'Native American' and 'MMM'. Bibliographies of selected articles, previously published reviews and high-yield journals will also be searched. All included papers will be evaluated for quality and bias using NIH Quality Assessment Tools for Observational Studies. A description of the study findings will be presented in a tabular format organised by outcome of interest along with study characteristics. ETHICS AND DISSEMINATION: There are no formal ethics approvals needed for this protocol. The findings of this systematic review will be shared with academic, governmental, community-based, institutes and NA (tribal) entities via a published peer-reviewed article, informational brief, poster and oral presentations. PROSPERO REGISTRATION NUMBER: CRD42022363405.

Community health worker intervention improves early childhood vaccination rates: results from a propensity-score matching evaluation.

BACKGROUND: Arizona's Health Start Program is a statewide community health worker (CHW) maternal and child health home visiting intervention. The objective of this study was to test if participation in Health Start during 2006-2016 improved early childhood vaccination completion rates. METHODS: This retrospective study used 11 years of administrative, birth certificate, and immunization records. Propensity score matching was used to identify control groups, based on demographic, socioeconomic, and geographic characteristics. Results are reported by historically disadvantaged subgroups and/or with a history of low vaccine uptake, including Hispanic/Latinx and American Indian children, and children of low socioeconomic status and from rural areas, children with teen mothers and first-born children. The average treatment-on-the-treated (ATT) effect estimated the impact of Health Start on timely completion of seven early childhood vaccine series: diphtheria/tetanus toxoids and acellular/whole-cell pertussis (DTaP/DTP), Haemophilus influenzae type b (Hib), hepatitis B (Hep. B), measles-mumps-rubella (MMR), pneumococcal conjugate vaccine (PCV13), poliovirus, and varicella. RESULTS: Vaccination completion rates (by age five) were 5.0% points higher for Health Start children as a group, and on average 5.0% points higher for several subgroups of mothers: women from rural border counties (ATT 5.8), Hispanic/Latinx women (ATT 4.8), American Indian women (ATT 4.8), women with less than high school education (ATT 5.0), teen mothers (ATT 6.1), and primipara women (ATT 4.5), compared to matched control groups (p-value ≤ 0.05). Time-to-event analyses show Health Start children complete vaccination sooner, with a hazard rate for full vaccination 13% higher than their matches. CONCLUSION: A state-operated home visiting intervention with CHWs as the primary interventionist can effectively promote early childhood vaccine completion, which may reduce the incidence of preventable diseases and subsequently improve children's health. Effects of CHW interventions on vaccination uptake is particularly relevant given the rise in vaccine-preventable diseases in the US and globally. TRIAL REGISTRATION: Approved by the University of Arizona Research Institutional Review Board (Protocol 1701128802), 25 January 2017.

Addressing maternal and child health equity through a community health worker home visiting intervention to reduce low birth weight: retrospective quasi-experimental study of the Arizona Health Start Programme.

OBJECTIVE: To test if participation in the Health Start Programme, an Arizona statewide Community Health Worker (CHW) maternal and child health (MCH) home visiting programme, reduced rates of low birth weight (LBW), very LBW (VLBW), extremely LBW (ELBW) and preterm birth (PTB). DESIGN: Quasi-experimental retrospective study using propensity score matching of Health Start Programme enrolment data to state birth certificate records for years 2006-2016. SETTING: Arizona is uniquely racially and ethnically diverse with comparatively higher proportions of Latino and American Indian residents and a smaller proportion of African Americans. PARTICIPANTS: 7212 Health Start Programme mothers matched to non-participants based on demographic, socioeconomic and geographic characteristics, health conditions and previous birth experiences. INTERVENTION: A statewide CHW MCH home visiting programme. PRIMARY AND SECONDARY OUTCOME MEASURES: LBW, VLBW, ELBW and PTB. RESULTS: Using Health Start Programme's administrative data and birth certificate data from 2006 to 2016, we identified 7212 Health Start Programme participants and 53 948 matches. Programme participation is associated with decreases in adverse birth outcomes for most subgroups. Health Start participation is associated with statistically significant lower rates of LBW among American Indian women (38%; average treatment-on-the-treated effect (ATT): 2.30; 95% CI -4.07 to -0.53) and mothers with a pre-existing health risk (25%; ATT: -3.06; 95% CI -5.82 to -0.30). Among Latina mothers, Health Start Programme participation is associated with statistically significant lower rates of VLBW (36%; ATT: 0.35; 95% CI -0.69 to -0.01) and ELBW (62%; ATT: 0.31; 95% CI (-0.52 to -0.10)). Finally, Health Start Programme participation is associated with a statistically significant lower rate of PTB for teen mothers (30%; ATT: 2.81; 95% CI -4.71 to -0.91). Other results were not statistically significant. CONCLUSION: A state health department-operated MCH home visiting intervention that employs CHWs as the primary interventionist may contribute to the reduction of LBW, VLBW, ELBW and PTB and could improve birth outcomes statewide, especially among women and children at increased risk for MCH inequity.

Evaluation protocol to assess maternal and child health outcomes using administrative data: a community health worker home visiting programme.

INTRODUCTION: Emerging evidence suggests community health workers (CHWs) delivering preventive maternal and child health (MCH) interventions through home visiting improve several important health outcomes, including initiation of prenatal care, healthy birth weight and uptake of childhood immunisations. METHODS AND ANALYSIS: The Arizona Health Start Program is a behavioral-based home visiting intervention, which uses CHWs to improve MCH outcomes through health education, referral support, and advocacy services for at-risk pregnant and postpartum women with children up to 2 years of age. We aim to test our central hypothesis that mothers and children exposed to this intervention will experience positive health outcomes in the areas of (1) newborn health; (2) maternal health and healthcare utilisation; and (3) child health and development. This paper outlines our protocol to retrospectively evaluate Health Start Program administrative data from 2006 to 2015, equaling 15 576 enrollees. We will use propensity score matching to generate a statistically similar control group. Our analytic sample size is sufficient to detect meaningful programme effects from low-frequency events, including preterm births, low and very low birth weights, maternal morbidity, and differences in immunisation and hospitalisation rates. ETHICS AND DISSEMINATION: This work is supported through an inter-agency contract from the Arizona Department of Health Services and is approved by the University of Arizona Research Institutional Review Board (Protocol 1701128802, approved 25 January 2017). Evaluation of the three proposed outcome areas will be completed by June 2020.

Centers for Disease Control and Prevention's Temporary Epidemiology Field Assignee program: Supporting state and local preparedness in the wake of Ebola.

OBJECTIVES: The Centers for Disease Control and Prevention launched the Temporary Epidemiology Field Assignee (TEFA) Program to help state and local jurisdictions respond to the risk of Ebola virus importation during the 2014-2016 Ebola Outbreak in West Africa. We describe steps taken to launch the 2-year program, its outcomes and lessons learned. METHODS: State and local health departments submitted proposals for a TEFA to strengthen local capacity in four key public health preparedness areas: 1) epidemiology and surveillance, 2) health systems preparedness, 3) health communications, and 4) incident management. TEFAs and jurisdictions were selected through a competitive process. Descriptions of TEFA activities in their quarterly reports were reviewed to select illustrative examples for each preparedness area. RESULTS: Eleven TEFAs began in the fall of 2015, assigned to 7 states, 2 cities, 1 county and the District of Columbia. TEFAs strengthened epidemiologic capacity, investigating routine and major outbreaks in addition to implementing event-based and syndromic surveillance systems. They supported improvements in health communications, strengthened healthcare coalitions, and enhanced collaboration between local epidemiology and emergency preparedness units. Several TEFAs deployed to United States territories for the 2016 Zika Outbreak response. CONCLUSION: TEFAs made important contributions to their jurisdictions' preparedness. We believe the TEFA model can be a significant component of a national strategy for surging state and local capacity in future high-consequence events.

Using Predictive Evaluation to Design, Evaluate, and Improve Training for Polio Volunteers.

BACKGROUND: Predictive Evaluation (PE) uses a four-step process to predict results then designs and evaluates a training intervention accordingly. In 2012, the Sustainable Management Development Program (SMDP) at the Centers for Disease Control and Prevention used PE to train Stop Transmission of Polio (STOP) program volunteers. METHODS: Stakeholders defined specific beliefs and practices that volunteers should demonstrate. These predictions and adult learning practices were used to design a curriculum to train four cohorts. At the end of each workshop, volunteers completed a beliefs survey and wrote goals for intended actions. The goals were analyzed for acceptability based on four PE criteria. The percentage of acceptable goals and the beliefs survey results were used to define the quality of the workshop. A postassignment adoption evaluation was conducted for two cohorts, using an online survey and telephone or in-person structured interviews. The results were compared with the end of workshop findings. RESULTS: The percentage of acceptable goals across the four cohorts ranged from 49% to 85%. In the adoption evaluation of two cohorts, 88% and 94% of respondents reported achieving or making significant progress toward their goal. A comparison of beliefs survey responses across the four cohorts indicated consistencies in beliefs that aligned with stakeholders' predictions. CONCLUSIONS: Goal statements that participants write at the end of a workshop provide data to evaluate training quality. Beliefs surveys surface attitudes that could help or hinder workplace performance. The PE approach provides an innovative framework for health worker training and evaluation that emphasizes performance.

Comparison of health confidence in rural, suburban and urban areas in the UK and the USA: a secondary analysis.

OBJECTIVE: Confidence in healthcare may influence the patients' utilisation of healthcare resources and perceptions of healthcare quality. We sought to determine whether self-reported confidence in healthcare differed between the UK and the USA, as well as by rurality or urbanicity. DESIGN: A secondary analysis of a subset of survey questions regarding self-reported confidence in healthcare from the 2010 Commonwealth Fund International Health Policy Survey. SETTING: Telephone survey of participants from the UK and the USA. PARTICIPANTS: Our final analysis included 1511 UK residents (688 rural, 446 suburban, 372 urban, 5 uncategorised) and 2501 US residents (536 rural, 1294 suburban, 671 urban). OUTCOME MEASURES: Questions assessed respondents' confidence in the effectiveness and affordability of the treatment. We compared survey outcomes from these questions between, and within, the two regions and among, and within, residence types (rural, suburban and urban). RESULTS: Significant differences were found in self-reported confidence in healthcare between the UK and US, among residence types, and between the two regions within residence types. Reported levels were higher in the UK. Within regions, significant differences by residence type were found for the US, but not the UK. Within the US, suburban respondents had the highest self-reported confidence in healthcare. CONCLUSIONS: Significant differences exist between the UK and US in confidence in healthcare. In the US, but not in the UK, self-reported confidence is related to residence type. Within countries, significant differences by residence type were found for the US, but not the UK. Our findings warrant the examination of causes for relative confidence levels in healthcare between regions and among US residence types.