Attitudes Toward COVID-19 Vaccines Among Pregnant and Recently Pregnant Individuals.

Importance: Pregnant people and infants are at high risk of severe COVID-19 outcomes. Understanding changes in attitudes toward COVID-19 vaccines among pregnant and recently pregnant people is important for public health messaging. Objective: To assess attitudinal trends regarding COVID-19 vaccines by (1) vaccination status and (2) race, ethnicity, and language among samples of pregnant and recently pregnant Vaccine Safety Datalink (VSD) members from 2021 to 2023. Design, Setting, and Participants: This cross-sectional surveye study included pregnant or recently pregnant members of the VSD, a collaboration of 13 health care systems and the US Centers for Disease Control and Prevention. Unvaccinated, non-Hispanic Black, and Spanish-speaking members were oversampled. Wave 1 took place from October 2021 to February 2022, and wave 2 took place from November 2022 to February 2023. Data were analyzed from May 2022 to September 2023. Exposures: Self-reported or electronic health record (EHR)-derived race, ethnicity, and preferred language. Main Outcomes and Measures: Self-reported vaccination status and attitudes toward monovalent (wave 1) or bivalent Omicron booster (wave 2) COVID-19 vaccines. Sample- and response-weighted analyses assessed attitudes by vaccination status and 3 race, ethnicity, and language groupings of interest. Results: There were 1227 respondents; all identified as female, the mean (SD) age was 31.7 (5.6) years, 356 (29.0%) identified as Black race, 555 (45.2%) identified as Hispanic ethnicity, and 445 (36.3%) preferred the Spanish language. Response rates were 43.5% for wave 1 (652 of 1500 individuals sampled) and 39.5% for wave 2 (575 of 1456 individuals sampled). Respondents were more likely than nonrespondents to be White, non-Hispanic, and vaccinated per EHR. Overall, 76.8% (95% CI, 71.5%-82.2%) reported 1 or more COVID-19 vaccinations; Spanish-speaking Hispanic respondents had the highest weighted proportion of respondents with 1 or more vaccination. Weighted estimates of somewhat or strongly agreeing that COVID-19 vaccines are safe decreased from wave 1 to 2 for respondents who reported 1 or more vaccinations (76% vs 50%; χ21 = 7.8; P < .001), non-Hispanic White respondents (72% vs 43%; χ21 = 5.4; P = .02), and Spanish-speaking Hispanic respondents (76% vs 53%; χ21 = 22.8; P = .002). Conclusions and Relevance: Decreasing confidence in COVID-19 vaccine safety in a large, diverse pregnant and recently pregnant insured population is a public health concern.

Increasing access to family planning services among women receiving medications for opioid use disorder: A pilot randomized trial examining a peer-led navigation intervention.

OBJECTIVE: High rates of unintended pregnancy occur among women with opioid use disorder (OUD). OUD treatment settings may provide an ideal opportunity to address the family planning needs of patients. However, few studies have rigorously evaluated interventions designed to address family planning needs in the OUD treatment setting. This study assessed the feasibility, acceptability, and preliminary efficacy of a peer-led navigation intervention designed to educate and link women receiving medications for OUD to family planning services. METHODS: The study recruited women from four OUD treatment programs in Denver, Colorado, to participate in a pilot randomized controlled trial from March 2018 to February 2019. Eligible participants were English-speaking adult females who were neither pregnant nor desiring a pregnancy and who were not using a long-acting reversible contraceptive (LARC) method. Participants completed a baseline survey, and the study randomized them to receive a two-session, peer-led family planning navigation intervention or usual care. The study assessed feasibility by participant engagement in the intervention. The study used follow-up self-report surveys and electronic health record data to assess intervention acceptability and intervention efficacy for the primary outcomes of a family planning visit and use of a LARC method. RESULTS: The study enrolled 119 women who were randomized to the Sexual Health Initiative for Navigation and Empowerment (SHINE) peer-led navigation intervention (n = 56) or usual care (n = 63). The average age was 32 (SD = 6.4); 76% were receiving methadone, 24% were receiving buprenorphine and 19% reported a treatment provider had ever discussed family planning with them. Most had a previous pregnancy (82%) and of these, 93% reported an unplanned pregnancy. Among intervention participants, 93% completed the first navigation session, 90% felt that intervention topics were important, 76% indicated that the information was new, and 82% found working with a peer helpful. At six months postbaseline, significantly more (p = 0.01) intervention participants (36%) received a family planning visit compared to control participants (14%). There was no between-group difference on use of LARC methods. CONCLUSIONS: A peer-led family planning navigation intervention was feasible to implement, acceptable to participants, and showed evidence of preliminary efficacy. This model may be an effective and potentially sustainable approach to support the family planning needs of women in treatment for OUD.

Acceptability and Efficacy of a Sexual Health Texting Intervention Designed to Support Adolescent Females.

OBJECTIVE: To evaluate the feasibility, acceptability, and initial efficacy of a pilot texting intervention ("t4she") in primary care designed to increase sexual health knowledge and promote dual protection strategies to reduce unintended pregnancies and sexually transmitted infections among adolescent females. METHODS: Participants were recruited from 2 federally qualified health centers. Eligibility included: being 13 to 18 years of age; assigned female at birth; English-speaking; not currently pregnant and/or intending to become pregnant; and having texting capabilities. A randomized controlled trial assessed between-group differences at 3 and 6 months on knowledge, Health Belief Model constructs, and sexual behaviors. Input on intervention acceptability was obtained at 3 months. RESULTS: Among 244 participants enrolled and randomized, the average age was 16 (±1.6), 80% were Hispanic/Latina, 53% had ever had vaginal sex, and 50% had used prescription birth control with 24% currently using a long-acting reversible method. Among those sexually active, 29% reported consistent condom use and 24% reported engaging in dual protection behaviors at last sex. Among participants with all follow-up data (N = 136), intervention participants had significant increases in sexual health knowledge and reported more prescription birth control use at follow-up than control participants. No significant outcome differences were found for condom use or dual protection behaviors. Intervention participants reported receiving messages, being introduced to new information, and reading and sharing the messages. CONCLUSIONS: The pilot t4she sexual health intervention significantly improved knowledge and use of short-acting prescription birth control among young females in primary care and was acceptable by youth and feasible to implement.

Monitoring Depression Rates in an Urban Community: Use of Electronic Health Records.

OBJECTIVES: Depression is the most common mental health disorder and mediates outcomes for many chronic diseases. Ability to accurately identify and monitor this condition, at the local level, is often limited to estimates from national surveys. This study sought to compare and validate electronic health record (EHR)-based depression surveillance with multiple data sources for more granular demographic subgroup and subcounty measurements. DESIGN/SETTING: A survey compared data sources for the ability to provide subcounty (eg, census tract [CT]) depression prevalence estimates. Using 2011-2012 EHR data from 2 large health care providers, and American Community Survey data, depression rates were estimated by CT for Denver County, Colorado. Sociodemographic and geographic (residence) attributes were analyzed and described. Spatial analysis assessed for clusters of higher or lower depression prevalence. MAIN OUTCOME MEASURE(S): Depression prevalence estimates by CT. RESULTS: National and local survey-based depression prevalence estimates ranged from 7% to 17% but were limited to county level. Electronic health record data provided subcounty depression prevalence estimates by sociodemographic and geographic groups (CT range: 5%-20%). Overall depression prevalence was 13%; rates were higher for women (16% vs men 9%), whites (16%), and increased with age and homeless patients (18%). Areas of higher and lower EHR-based, depression prevalence were identified. CONCLUSIONS: Electronic health record-based depression prevalence varied by CT, gender, race/ethnicity, age, and living status. Electronic health record-based surveillance complements traditional methods with greater timeliness and granularity. Validation through subcounty-level qualitative or survey approaches should assess accuracy and address concerns about EHR selection bias. Public health agencies should consider the opportunity and evaluate EHR system data as a surveillance tool to estimate subcounty chronic disease prevalence.

A Multilevel Analysis of Individual, Health System, and Neighborhood Factors Associated with Depression within a Large Metropolitan Area.

Depression prevalence is known to vary by individual factors (gender, age, race, medical comorbidities) and by neighborhood factors (neighborhood deprivation). However, the combination of individual- and neighborhood-level data is rarely available to assess their relative contribution to variation in depression across neighborhoods. We geocoded depression diagnosis and demographic data from electronic health records for 165,600 patients seen in two large health systems serving the Denver population (Kaiser Permanente and Denver Health) to Denver's 144 census tracts, and combined these data with indices of neighborhood deprivation obtained from the American Community Survey. Non-linear mixed models examined the relationships between depression rates and individual and census tract variables, stratified by health system. We found higher depression rates associated with greater age, female gender, white race, medical comorbidities, and with lower rates of home owner occupancy, residential stability, and higher educational attainment, but not with economic disadvantage. Among the Denver Health cohort, higher depression rates were associated with higher crime rates and a lower percent of foreign born residents and single mother households. Our findings suggest that individual factors had the strongest associations with depression. Neighborhood risk factors associated with depression point to low community cohesion, while the role of education is more complex. Among the Denver Health cohort, language and cultural barriers and competing priorities may attenuate the recognition and treatment of depression.

Effect of a multi-modal intervention on immunization rates in obstetrics and gynecology clinics.

BACKGROUND: There is increasing attention on immunizations by obstetrician-gynecologists and a need to improve vaccination rates for all women. OBJECTIVE: To evaluate the effect of a multimodal intervention on rates of immunization with tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); and influenza in outpatient obstetrics and gynecology clinics. STUDY DESIGN: Immunization rates at 2 clinics were compared pre- and post-implementation of multiple interventions at a public integrated health-care system. Study interventions began on June 6, 2012 and concluded on May 31, 2014; the preimplementation time period used was June 6, 2010 to June 5, 2012. Interventions included stocking of immunizations in clinics, revision and expansion of standing orders, creation of a reminder/recall program, identification of an immunization champion to give direct provider feedback, expansion of a payment assistance program, and staff education. All women aged 15 and older who made a clinic visit during influenza season were included in the influenza cohort; women who delivered an infant during the study time period and had at least 1 prenatal visit within 9 months preceding delivery were included in the Tdap cohort; each clinic visit by a nonpregnant woman aged 15-26 years was assessed and included in the HPV analysis as an eligible visit if the patient was lacking any of the 3 HPV vaccines in the series. The primary outcome was receipt of influenza and Tdap vaccine per current American College of Obstetricians and Gynecologists guidelines and receipt of HPV vaccine during eligible visits. Influenza and Tdap were assessed with overall coverage rates at the institutional level, and HPV was assessed at the visit level by captured opportunities. All analyses included generalized estimating equations and the primary outcome was assessed with time as a covariate in all models. RESULTS: A total of 19,409 observations were included in the influenza cohort (10,231 pre- and 9178 post-intervention), 2741 in the Tdap cohort (1248 pre- and 1493 post-intervention), and 12,443 in the HPV cohort (7966 pre- and 4477 post-intervention). Our population was largely Hispanic, English-speaking, and publicly insured. The rate of influenza vaccination increased from 35.4% pre-intervention to 46.0% post-intervention (P < .001). The overall rate for Tdap vaccination increased from 87.6% pre-intervention to 94.5% post-intervention until the recommendation to vaccinate during each pregnancy was implemented (z = 4.58, P < .0001). The average Tdap up-to-date rate after that recommendation was 75.0% (z = -5.77, P < .0001). The overall rate of HPV vaccination with an eligible visit increased from 7.1% before to 23.7% after the intervention. CONCLUSION: Using evidence-based practices largely established in other settings, our intervention was associated with increased rates of influenza, Tdap, and HPV vaccination in outpatient underserved obstetrics and gynecology clinics. Integrating such evidence-based practices into routine obstetrics and gynecology care could positively impact preventive health for many women.

A mobile health infrastructure to support underserved patients with chronic disease.

BACKGROUND: Chronic diseases are the global leading cause of death, but the US health system is poorly designed to support patients with chronic disease. Underserved patients report high rates of cell phone use and interest in using mobile technology for health care. A mobile health infrastructure may help transform health care delivery for underserved patients with chronic disease. PROBLEM: This study assessed the feasibility of integrating mobile health infrastructure with clinical information systems and the electronic medical record (EMR) to support patients with chronic disease through automated, bidirectional text messaging. GOALS: Three priority areas of chronic disease management were targeted. Existing self-management support was expanded, and new support for laboratory test scheduling and medication management was created. STRATEGY: Adult patients (n=135) with diabetes selected preferred content and scheduling for self-management message prompts. Outreach messages were sent to patients overdue for laboratory tests and medications. Manual review of pharmacy and laboratory outreach data was conducted for quality assurance. Focus groups were held to solicit patient perspectives. RESULTS: Patients sent over 6500 response messages with response rates of 53.7% (blood sugar), 48.8% (step counts), and 31.9% (blood pressure). Laboratory data integration was achieved, but pharmacy data gaps required ongoing manual review. Focus group participants reported improved self-management and information awareness. IMPLICATIONS: HIT was used to address dependency on visit-bound disease management in a novel, low-cost way. Use of a mobile health infrastructure was feasible. Text messaging solutions may mitigate barriers to access and enhance support for patients with chronic disease.

Diabetes population management by telephone visits.

INTRODUCTION: Little has been published on the impact of telephone visits on diabetes outcome performance. RESEARCH DESIGN AND METHODS: An attending and resident physician prioritized telephone visits based on glycemic, blood pressure, and lipid performance. The resident and attending panel was compared with all other diabetic patients at the clinic for baseline and end-intervention performance. RESULTS: The intervention patients had an absolute percentage of increase versus control patients of 14.9 (p<0.01), 13.9 (p<0.01), and 8.3 (p=0.01) for HbA1c <9%, low-density lipoprotein <100 mg/dL, and blood pressure <130/80 mm Hg, respectively. CONCLUSIONS: This pilot study suggests that provider-driven telephone visits may be a means for healthcare systems to improve chronic disease outcomes as they transition to new paradigms of chronic care delivery. LIMITATIONS: This study was neither randomized nor blinded, was susceptible to an interventionist effect, and did not analyze for differences in baseline medication use.

The impact of tailored diabetes registry report cards on measures of disease control: a nested randomized trial.

BACKGROUND: Most studies of diabetes self-management that show improved clinical outcome performance involve multiple, time-intensive educational sessions in a group format. Most provider performance feedback interventions do not improve intermediate outcomes, yet lack targeted, patient-level feedback. METHODS: 5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested randomized trial. Half of the patients received report card mailings quarterly; patients at 4 of 8 clinics received report cards at every clinic visit; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data. Expert-recommended glycemic, lipid, and blood pressure outcomes were assessed. Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews. RESULTS: Many providers and the majority of patients perceived the patient report card as being an effective tool. However, patient report card mailings did not improve process outcomes, nor did point-of-care distribution improve intermediate outcomes. Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics (6.4% vs 3.8% respectively, Generalized estimating equations Standard Error 0.014, p < 0.001, CI -0.131 - -0.077). Provider reaction to performance feedback was mixed, with some citing frustration with the lack of both time and ancillary resources. CONCLUSIONS: Patient performance report cards were generally well received by patients and providers, but were not associated with improved outcomes. Targeted, patient-level feedback to providers improved glycemic performance. Provider frustration highlights the need to supplement provider outreach efforts. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00827710.

Changes in insurance status and access to care in an integrated safety net healthcare system.

This paper focuses on a cohort of uninsured patients that have accessed outpatient healthcare services in an urban safety net, evaluating the degree to which they switch insurance status and the impact this switching has on access to care. The results indicate that in an integrated safety net system, there is a high frequency of insurance status switching by the uninsured. Uninsured patients who switch to insured status were found to be more likely to visit specialty points of care and less likely to visit urgent points of care than the continuously uninsured. It is well documented that insurance coverage and continuity of care influence health status. Continuity of insurance coverage also has an impact on access to care for those receiving services within a safety net healthcare system.

Fatalities assessed by the Orange County child death review team, 1989 to 1991.

Interagency child death review teams have emerged in response to the increasing awareness of severe violence perpetrated against children in the United States. Child death review involves a systematic, multidisciplinary, and multiagency process to coordinate data and resources from the coroner, law enforcement, the courts, child protective services, and health care providers. The Orange County, CA team reviews all coroner's cases (unattended death or questionable cause of death) for children 12 years old and younger. This paper describes the interagency review in Orange County and provides data on the demographics of cases reviewed by the team (N = 637) compared to unreviewed deaths (N = 1,463) for the period 1989 to 1991. Trends were analyzed to assess differences in: (1) age distribution; (2) gender; (3) ethnicity; (4) cause of death (non-SIDS natural; non-natural including traffic deaths, SIDS, other injuries; homicide; and undetermined); and (5) cause of death by age, gender, and ethnicity. Implications of the data for other jurisdictions with child death review teams are discussed.

Goldhelox: a soft x-ray solar telescope.

The Goldhelox Project is the construction and use of a near-normal incidence soft x-ray robotic solar telescope by undergraduate students at Brigham Young University. Once it is completed and tested, it will be deployed from a Get-Away-Special (GAS) canister in the bay of a space shuttle. It will image the sun at a wavelength of 171-181Å with a time resolution of 1 sec and a spatial resolution of 2.5 arcsec. The observational bandpass was chosen to image x-rays from highly ionized coronal Fe lines. The data will be an aid in better understanding the beginning phases of solar flares and how flaring relates to the physics of the corona-chromosphere transition region. Goldhelox is tentatively scheduled to fly on a space shuttle sometime in 1995 or 1996. This paper outlines the project goals, basic instrument design, and the unique aspects of making this an undergraduate endeavor.

A model for answering the substance abuse educational needs of health professionals: the North Carolina Governor's Institute on Alcohol and Substance Abuse.

Physicians can play an increased role in recognizing, intervening, and moderating their patients' misuse of alcohol and other drugs. This article explores the need for educational changes to permit physicians to develop skills in prevention, screening, and office-based treatment. It includes a personal account by one of the authors of his experience in recognizing deficiencies in substance abuse education both in his own medical school training and in today's health science curricula in the United States. It reviews prior initiatives by NIAAA/NIDA to address curriculum needs and describes an innovative collaborative model in North Carolina called the Governor's Institute on Alcohol and Substance Abuse. The Institute was created in 1990 as a nonprofit corporation to promote education, research, and communication among health professionals. Some of the Institute's programs are described, including its curriculum integration project in the state's four medical schools. The article concludes that the time is right to introduce substance abuse concepts into basic and continuing education for all health professionals.

Testing the sexually abused child for the HIV antibody: issues for the social worker.

The frequency of HIV transmission to children and adolescents through sexual abuse is unknown. Because the incidences of HIV infection and of reported sexual abuse are both increasing, the transmission of HIV to children through sexual abuse may also be increasing. Social workers may have expanding roles in the decision-making process for testing and subsequent management of children infected with HIV through sexual abuse. This article discusses the benefits of identifying children who have been infected with HIV through sexual abuse and reviews guidelines for testing. Social workers can contribute to test decision making in instances when perinatal HIV transmission is a possibility, when it may be possible to test the assailant, and when parents or legal guardians insist on testing the child. Other issues discussed include family education and coping, physical education and support, social casework and research with pedophiles, and service needs for care and follow-up of children found to be HIV infected as a result of sexual abuse.

Situational and sociodemographic characteristics of children infected with human immunodeficiency virus from pediatric sexual abuse.

This study assessed the situational and sociodemographic characteristics of children infected with human immunodeficiency virus (HIV) from pediatric sexual abuse. A letter of inquiry was sent to 2147 professionals across health and social service disciplines involved with child abuse assessment, treatment, and prevention. Respondents working in programs where HIV antibody testing of abuse victims occurs and who had identified HIV infection in one or more abused children were sent a survey to assess the demographics of victims, the family/living situation where abuse occurred, alternative risks for HIV infection, bases for diagnosis of sexual abuse and for HIV antibody testing, and profiles of the perpetrator and type of abuse. Of 5622 estimated HIV antibody tests conducted during 113,198 sex abuse assessments, 28 children were infected with HIV and lacked any alternative transmission route to that of sexual abuse. A total of 41 HIV-infected children with a history of sexual abuse were identified. Thirteen cases had alternative risk factors and were excluded from analysis. Sixty-four percent of the 28 victims with sexual abuse as the sole risk factor were female and 71% were African-American. The mean age was 9 years. Coinfection with another sexually transmitted disease (STD) occurred in 9 (33%) cases. Sexual abuse was diagnosed on the basis of a victim disclosure in 21 (75%) cases. The basis for HIV antibody testing was physical findings suggestive of HIV infection in 9 (32%) cases, HIV-seropositive or high-risk perpetrator in 6 (21%) and 2 (7%) cases, respectively, and the presence of another STD in the victim in 4 (14%) cases. Perpetrators were a child's parent in 10 (42%) cases and another relative in 6 (25%) cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Origins and clinical relevance of child death review teams.

Interagency child death review teams have emerged in response to the increasing awareness of severe violence against children in the United States. Since 1978, when the first team originated in Los Angeles, Calif, child death review teams have been established across the nation. Approximately 100 million Americans or 40% of the nation's population now live in counties or states served by such teams; most have been formed since 1988. Multiagency child death review involves a systematic, multidisciplinary, and multiagency process to coordinate and integrate data and resources from coroners, law enforcement, courts, child protective services, and health care providers. This article provides an introduction to the unique factors and magnitude of suspicious child deaths, and to the concept and process of interagency child death review. Future expansion of this process should lead to more effective multiagency case management and prevention of future deaths and serious injuries to children from child abuse and neglect.

Sudden infant death syndrome in infants of substance-abusing mothers.

A population-based study was performed to determine whether substance abuse during the perinatal period may be a risk factor for sudden infant death syndrome (SIDS). The incidence of SIDS was studied in 2143 infants of substance-abusing mothers (ISAM) born in Los Angeles County during 1986 and 1987 who were reported to the Los Angeles County Department of Health Services because of a history of drug exposure or positive urine test results in the mother, infant, or both. By comparing the ISAM birth reports with records of autopsy-proven SIDS in Los Angeles County, we found 19 SIDS cases in the population of 2143 ISAM, a SIDS rate of 8.87 cases per 1000 ISAM (95% confidence interval 5.3 to 13.8). This was significantly higher than the SIDS rate for the non-ISAM general population: 396 SIDS deaths among 325,372 live births, an incidence rate of 1.22 cases per 1000 births, p less than 0.00001. The age of ISAM at death was 99 +/- 63 (mean +/- SD) days compared with 91 +/- 52 days for the non-ISAM population (not significant). The incidence of SIDS was significantly greater in male infants, during the winter months, in black infants, and in non-Hispanic white infants in the non-ISAM population. Such differences were not observed in the ISAM group. A greater incidence of symptomatic apnea was reported before SIDS for the ISAM than for the non-ISAM population (22% vs 5.4%, p = 0.022). We conclude that ISAM have a higher incidence of SIDS than the non-ISAM general population. However, it was not possible to separate maternal substance abuse from other confounding variables that may also have had an impact on SIDS risk in the ISAM group.