Organ weights and length anthropometry measures at autopsy for sudden infant death syndrome cases and other infant deaths in the Chicago infant mortality study.

Organ weights are a possible diagnostic or pathophysiological clue to distinguishing sudden infant death syndrome (SIDS) cases from other infant deaths but suffer from major confounding. Using autopsy data from the Chicago Infant Mortality Study, a majority African-American case-control study of deceased infants under 1 year conducted 1993-96, we assessed differences in the weights of brain, thymus, kidneys, lungs, liver, spleen, total body, and four length anthropometry measures in SIDS-diagnosed infants compared to controls. Using exact and coarsened matching, we ran Bayesian linear models with these anthropometry outcomes and repeated the analyses substituting the corresponding fitted allometrically-scaled organ weight indices to account for body size. After detailed analysis and adjustment for potential confounders, we found that matched SIDS infants were generally bigger than controls, with higher mean brain, liver, spleen, thymus, lung, and total body weights, and higher mean head and chest circumference, crown-heel, crown-rump lengths. SIDS infants also had higher mean thymus, liver, spleen, lung and total body weight indices. The association with thymus weight was proportionately greater in magnitude than any other outcome measure and independent of body size. The results of these more detailed analyses are consistent with recent findings from other studies with differing racial compositions, and substantially confirm the primary organ sites for more detailed mechanistic research into the biological dysregulation contributing to underlying pathophysiology of SIDS.

Maternal Education and Child Self-Regulation: Do Maternal Self-Regulation and Responsiveness Mediate the Association?

OBJECTIVE: To examine the mediating role of observed maternal responsiveness and maternal self-regulation on the association between maternal education and children's self-regulation. METHODS: English-speaking mother-child dyads (n = 189) were recruited from a previous study and were eligible if the child was kindergarten eligible at the start of the 2020 to 2021 or 2021 to 2022 school year. Key measures included: Difficulties in Emotion Regulation Scale-Short Form for maternal emotional self-regulation, Culturally Affirming and Responsive Experiences for maternal responsiveness, and the Head-Toes-Knees-Shoulders for child self-regulation. The association between years of maternal education and child self-regulation was examined with linear regression, and the mediation analyses utilized 4 subsequent steps examining their relations. These steps were checked through a series of linear regressions, and beta weights were used to describe associations. Each potential mediator was examined separately. RESULTS: Children of mothers with higher education had significantly higher self-regulation, slope of 1.3 (95% confidence interval 0.3, 2.4, P = 0.015, beta = 0.18). Further, mothers with higher education had significantly higher observed responsiveness. The beta-weight of 0.34 (P < 0.001) supported maternal responsiveness as a mediator. Finally, in the test for direct and indirect effects, observed maternal responsiveness explained 29% (95% confidence interval 3.3%, 115%) of the association between maternal education and child self-regulation. CONCLUSIONS: This study highlights a key mechanism related to children's self-regulation skills and the significant role of observed maternal responsiveness in explaining the association between maternal education and child self-regulation.

Characteristics of Sudden Unexpected Infant Deaths on Shared and Nonshared Sleep Surfaces.

OBJECTIVES: Describe characteristics of sudden unexpected infant deaths (SUID) occurring on shared or nonshared sleep surfaces. METHODS: We examined SUID among residents of 23 US jurisdictions who died during 2011 to 2020. We calculated frequencies and percentages of demographic, sleep environment, and other characteristics by sleep surface sharing status and reported differences of at least 5% between surface sharing and nonsharing infants. RESULTS: Of 7595 SUID cases, 59.5% were sleep surface sharing when they died. Compared with nonsharing infants, sharing infants were more often aged 0 to 3 months, non-Hispanic Black, publicly insured, found supine, found in an adult bed or chair/couch, had a higher number of unsafe sleep factors present, were exposed to maternal cigarette smoking prenatally, were supervised by a parent at the time of death, or had a supervisor who was impaired by drugs or alcohol at the time of death. At least 76% of all SUID had multiple unsafe sleep factors present. Among surface-sharing SUID, most were sharing with adults only (68.2%), in an adult bed (75.9%), and with 1 other person (51.6%). Surface sharing was more common among multiples than singletons. CONCLUSIONS: Among SUID, surface sharing and nonsharing infants varied by age at death, race and ethnicity, insurance type, presence of unsafe sleep factors, prenatal smoke exposure, and supervisor impairment. Most SUID, regardless of sleep location, had multiple unsafe sleep factors present, demonstrating the need for comprehensive safe sleep counseling for every family at every encounter.

Designing mobile health to align with the social determinants of health.

The maternal health crisis in the United States is becoming increasingly worse, with disparities continuing to escalate among marginalized populations. mHealth can contribute to addressing the Social Determinants of Health (SDOH) that produce inequities in maternal morbidity and mortality. Reducing inequities through mHealth can be achieved by designing these technologies to align with SDOH. As mHealth developed to support maternal health has primarily supported the extension of clinical care, there is an opportunity to integrate frameworks and methods from human factors/ergonomics and public health to produce thorough comprehension of SDOH through intentional partnerships with marginalized populations. Potential for this opportunity is presented through a case study derived from a community-based participatory research process focused on transportation access to maternal health services. Through multi-faceted, interdisciplinary, and community-based approaches to designing mHealth that attends to the systemic factors that generate and escalate inequities, improvements in the maternal health crisis could be realized.

Maternal Informal Learning Experiences that Shape Parenting Practices.

Objective: Current understanding of the linkage between maternal education and parenting practices has largely been informed using a narrow definition of educational attainment-the highest level of education an individual has completed. However, the proximal processes that shape parenting, including informal learning experiences, are also important to understand. Less is known about the informal learning experiences that shape parenting decisions and practices. To this end, we conducted a qualitative inquiry about the informal learning experiences of mothers of children ages 3 to 4 years with the specific goal of understanding how maternal informal learning experiences shape parenting decisions and practices. Design: We conducted interviews with 53 mothers from across the United States who had previously participated in a randomized controlled trial (RCT) of an intervention targeting infant care practices. We recruited a purposive sample of mothers chosen to maximize diversity across educational attainment and adherence to infant care practices targeted in the RCT. Using a grounded theory approach, data were analyzed using an iterative process for organizing codes and themes that mothers identified as informal learning experiences. Results: We identified seven themes representing distinct types of maternal informal learning experiences that impact parenting practices, including: (1) experiential learning during childhood; (2) experiential learning during adulthood; (3) interpersonal interactions including via social media; (4) experiences with non-interactive media sources; (5) informal trainings; (6) beliefs; and (7) current circumstances. Conclusions: Multiple informal learning experiences inform the parenting decisions and practices of mothers with varying levels of formal educational attainment.

Access to Healthcare Among US Adult Refugees: A Systematic Qualitative Review.

Refugees encounter numerous healthcare access barriers in host countries, leading to lower utilization rates and poorer health outcomes. In the US, social inequities and fragmented health systems may exacerbate these disparities. Understanding these factors is necessary to ensure equitable care of refugee populations. A systematic literature review of qualitative studies on US adult refugee healthcare access from January 2000 to June 2021 was performed in accordance with PRISMA. Studies were analyzed deductively and then inductively to incorporate previous findings in other resettlement countries and emergence of US-specific themes. 64 articles representing 16+ countries of origin emerged from the final analysis, yielding nine interrelated themes related to health literacy, cost of services, cultural beliefs, and social supports, among others. The main challenges to refugees' healthcare access emerge from the interactions of care fragmentation with adverse social determinants. Given diverse barriers, integrated care models are recommended in treating refugee populations.

Integrated model of primary and mental healthcare for the refugee population served by an academic medical centre.

Refugees are at increased risk for developing mental health concerns due to high rates of trauma exposure and postmigration stressors. Moreover, barriers to accessing mental health services result in ongoing suffering within this population. Integrated care-which combines primary healthcare and mental healthcare into one cohesive, collaborative setting-may improve refugees' access to comprehensive physical and mental health services to ultimately better support this uniquely vulnerable population. Although integrated care models can increase access to care by colocating multidisciplinary services, establishing an effective integrated care model brings unique logistic (eg, managing office space, delineating roles between multiple providers, establishing open communication practices between specialty roles) and financial (eg, coordinating across department-specific billing procedures) challenges. We therefore describe the model of integrated primary and mental healthcare used in the International Family Medicine Clinic at the University of Virginia, which includes family medicine providers, behavioural health specialists and psychiatrists. Further, based on our 20-year history of providing these integrated services to refugees within an academic medical centre, we offer potential solutions for addressing common challenges (eg, granting specialty providers necessary privileges to access visit notes entered by other specialty providers, creating a culture where communication between providers is the norm, establishing a standard that all providers ought to be CC'ed on most visit notes). We hope that our model and the lessons we have learned along the way can help other institutions that are interested in developing similar integrated care systems to support refugees' mental and physical health.

Cases of Loiasis Among a Congolese Family: Screening for Loiasis Among Newly Arrived Refugees From Endemic Areas.

Loiasis is a parasitic infection caused by the filarial nematode Loa loa within endemic regions of West and Central Africa. These regions include areas co-endemic for other nematode infections. Although loiasis is rarely seen in the United States (US), primary care providers who regularly see refugees from endemic areas should be aware of its clinical presentation, diagnostic work-up, and initial management. Given the challenges of diagnosing loiasis, especially in low prevalence settings, we present cases of four family members, two of whom were diagnosed with loiasis, and discuss an approach to screening populations from endemic regions during their initial Refugee Health Examination upon arrival to the US.

Racial and Ethnic Disparities in Breastfeeding Continuation Among U.S. Hispanic Mothers: Identification of Mechanisms.

Objective: We examined the extent to which social, maternal, and infant factors and Theory of Planned Behavior (TPB) domains-attitudes, perceived control, and subjective norms-mediate the relationship between maternal race and ethnicity and birth country, and breastfeeding continuation. Materials and Methods: A nationally representative cohort of 2,810 mothers with self-reported race, ethnicity, and birth country was used. Main outcomes included any and exclusive breastfeeding at 2-6 months of infant age. A conceptual framework with the aforementioned mediators of interest was developed. Logistic regression was used to examine main associations, and structural equation modeling was used to identify the extent to which proposed mediators explained the relationship between independent and dependent variables. Results: One thousand two hundred twenty-one mothers were U.S.-born non-Hispanic white (NHW), 432 U.S.-born Hispanic, 329 Mexico-born Hispanic, 107 Central- or South America-born Hispanic, 33 Caribbean-born Hispanic, and 688 U.S.-born non-Hispanic black (NHB). No differences in breastfeeding continuation among U.S.-born NHW and U.S.-born Hispanic mothers were found. In contrast, compared with U.S.-born NHW mothers, Mexico-born (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.46-2.72) and Central- or South America-born (OR 3.42, 95% CI 1.89-6.17) Hispanic mothers had higher odds, and Caribbean-born Hispanic mothers had lower odds (OR 0.45, 95% CI 0.26-0.76) of any breastfeeding. These relationships were mediated by attitudes and subjective norms. Conclusions: Breastfeeding continuation among U.S. Hispanic mothers varied by birth country, highlighting the heterogeneity of breastfeeding populations of Hispanic mothers in the United States. Tailored interventions should strengthen policies supportive of positive attitudes toward and subjective norms around breastfeeding.

Advancing COVID-19 Vaccination Equity Among the Refugee Community: An Innovative Multi-Sector Collaborative Outreach Program.

INTRODUCTION: Multi-sector outreach collaborations have the potential to improve COVID-19 vaccine access among underserved populations, including refugees. METHODS: Using a four-pronged strategy, we offered the local refugee community COVID-19 vaccine appointments within the next week. RESULTS: Over a thousand (1,327) individuals from more than 20 countries were identified; mean age 36.5 (SD=16.4); 55% female. Initially, 613 (46%) reported being scheduled/vaccinated prior to outreach efforts; 312 (24%) appointments were scheduled that resulted from outreach efforts. By February 2022, 895 (67.4%) of the 1,327 patients had at least one dose; the majority of these were Pfizer (n=750, 84%). Of 895 with first dose, 843 completed two-dose series (94.2%). Overall completion rate of initial series was 63.5%. Reasons for declining (171, 13%) included wanting to speak with a physician or family member first; pregnancy hesitation; postponing until after Ramadan. DISCUSSION: Although lower than local and state rates, this refugee community's COVID-19 vaccine uptake is on par with the overall population in the United States (65.8%). Because of COVID-19's disproportionately negative impact on refugee and other underserved populations, we offer recommendations for future equity-informed efforts.

Predictors of cervical cancer screening for refugee women attending an international family medicine clinic in the United States.

PURPOSE: Cervical cancer screening (CCS) rates are lower for foreign-born women in the United States (U.S.) compared with the overall population. This study aimed to determine the CCS rate and predictors among refugees who were identified as female attending a family medicine clinic. METHODS: A retrospective chart review included refugee individuals aged 21+, seen in the previous 3 years (3/23/2015-3/20/2018), without hysterectomy (n = 525). Lab results determined CCS rate. Chi-square and logistic regression models explored predictors of CCS. RESULTS: Overall, 60.0% were up-to-date (UTD) on CCS. Individuals aged 30-49, married, and with [Formula: see text] 1 child had higher odds of being UTD. Ten or more years living in the U.S. was a significant bivariate predictor of CCS, and approached significance in the multivariate model. CONCLUSION: This study begins to fill gaps in knowledge about cervical cancer control among individuals who resettled in the U.S. as refugees and, given that CCS rates are suboptimal, informs clinical practice improvements and directions for future research.

Maternal Smoking, Alcohol and Recreational Drug Use and the Risk of SIDS Among a US Urban Black Population.

Background: Rates of sudden infant death syndrome (SIDS) are twice as high among Black infants compared to white infants in the US. While the contribution of sleep environment factors to this disparity is known, little is known about the risk of SIDS among Black infants in relation to maternal prenatal smoking, alcohol and drug use as well as infant smoke exposure. Objective: To assess the contribution of maternal substance use during pregnancy and the potential interactions with infant bedsharing in a high-risk, urban Black population. Methods: The Chicago Infant Mortality Study (CIMS) collected data on 195 Black infants who died of SIDS and 195 controls matched on race, age and birthweight. Risk of SIDS was calculated for maternal smoking, alcohol and drug use, adjusting for potential confounding variables and other risk factors for SIDS. Interactions between these substance use variables and bedsharing were also calculated. Results: Infants were more likely to die from SIDS if the mother smoked during pregnancy (aOR 3.90, 95% CI 1.37-3.30) and post-pregnancy (aOR 2.49, 95% CI 1.49-4.19). There was a dose response seen between amount smoked during pregnancy and risk of SIDS. Use of alcohol (aOR 2.89, 95% CI 1.29-6.99), cocaine (aOR 4.78, 95% CI 2.45-9.82) and marijuana (aOR 2.76, 95% CI 1.28-5.93) were associated with increased risk of SIDS. In the final, multivariable model controlling for sociodemographic factors and covariates, maternal smoking (aOR 3.03, 95% CI 1.03-8.88) and cocaine use (aOR 4.65, 95% CI 1.02-21.3) during pregnancy remained significant. There were significant, positive interactions between bedsharing and maternal smoking during pregnancy and post-pregnancy, alcohol use and cocaine use. Conclusion: Maternal use of tobacco, alcohol and cocaine during pregnancy is associated with significantly increased risk of SIDS in a Black, urban population. Reducing substance use and eliminating disparities in SIDS, sudden unexpected infant death (SUID) (also known as sudden unexpected death in infancy or SUDI) and infant mortality need to involve more than individual level education, but instead will require a comprehensive examination of the role of social determinants of health as well as a multi-pronged approach to address both maternal and infant health and wellbeing.

Prevalence of Helicobacter pylori infection among resettled refugees presenting to a family medicine clinic in the United States.

BACKGROUND: Although endemic to much of the global population, few studies have examined Helicobacter pylori (H. pylori) in US refugee populations. This study investigates the prevalence of H. pylori infection and barriers to treatment in the International Family Medicine Clinic (IFMC), a primary care refugee clinic, in central Virginia. MATERIALS AND METHODS: We conducted a chart review of 188 refugee patients of the IFMC who were referred for an H. pylori test between January 1, 2019, and December 31, 2020. Recorded measures included patient demographics, H. pylori test result, treatment of initial infection, completion of test of cure (TOC), TOC results, salvage therapy, and barriers to treatment. Binary logistic regression was performed to examine the association between demographic factors and H. pylori test results. RESULTS: Of the 171 patients who completed an H. pylori test, 94 tested positive (54.9%). Of the 93 patients that were subsequently treated, 76 were treated with clarithromycin triple therapy (82%). Forty-eight patients (52%) completed a TOC after completing treatment, and 21 (43%) of these patients remained positive, indicating persistent infection. Eighteen patients (90%) who remained positive for H. pylori were subsequently treated with quadruple therapy. Patients under 18 (OR = 0.25, p < 0.01) and patients with a history of previous H. pylori (OR = 0.44, p < 0.05) were less likely to have positive results on initial H. pylori testing. Common barriers to treatment included pregnancy, religious observance (e.g., fasting), and health system complications (e.g., prior authorization for medications, cost of treatment). CONCLUSIONS: The prevalence of H. pylori among refugees at the IFMC was higher than the overall prevalence estimate for the United States, which is consistent with previous studies. This work represents an updated picture of H. pylori prevalence among refugees in the United States and contributes to the identification of treatment barriers.

Telemedicine Use in Refugee Primary Care: Implications for Care Beyond the COVID-19 Pandemic.

The expansion of telemedicine during the COVID-19 pandemic offers an opportunity to reach vulnerable refugee communities with limited access to healthcare; however, there are limited data on characteristics of refugee patients that are associated with telemedicine use. We examined primary care encounters between March 2020 and February 2021. We compared telemedicine encounters among refugee and non-refugee patients and examined patient characteristics associated with telemedicine use in refugee patients. Overall, refugees used telemedicine less (aOR = 0.59, p < .001). Among refugee patients, telemedicine encounters were more likely if the patient had hypertension or diabetes, had an activated patient portal, carried private insurance and spoke English as their primary language. Telemedicine may be a useful modality of care management for refugee patients who require many follow-up visits; however, language barriers remain a concern. This is important to consider as telemedicine efforts continue and are expanded.

The Impact of Breastfeeding and Safe Sleep Mobile Health Messaging on Breastfeeding and Bedsharing.

OBJECTIVE: Mobile health (mHealth) safe sleep messaging increases rates of safe sleep. Bedsharing is more common among breastfeeders. Advice to not bedshare may negatively impact breastfeeding. We compared the impact of safe sleep or breastfeeding mHealth messaging on bedsharing and breastfeeding at 2 to 5 months. METHODS: This is a secondary analysis of mothers who initiated breastfeeding from a cluster randomized clinical trial of mHealth messaging for safe sleep or breastfeeding. A multi-ethnic sample of 1600 mothers was recruited from 16 US birth hospitals and surveyed at 2 to 5 months regarding the previous 2 weeks' breastfeeding and bedsharing practices. Data on 997 mothers who initiated breastfeeding were analyzed with multivariable generalized estimating logistic regression models to examine the association of mHealth messaging with infant care practices. RESULTS: Overall, exposure to breastfeeding versus safe sleep messaging was not associated with a difference in any breastfeeding at 2 to 5 months (69.3% vs 65.5%, respectively; adjusted odds ratio [aOR] = 1.33 [95% confidence interval, 0.91, 1.94]). Women with shorter planned duration of breastfeeding who received breastfeeding messaging had increased odds of breastfeeding at 2 to 5 months (50% vs 31%; aOR 3.13 [95% CI, 1.47, 6.65]). Mothers who received safe sleep messaging had lower rates of bedsharing overall when compared to breastfeeding messaging (24.8% vs 35.2%; aOR = 0.58 [95% CI, 0.44, 0.78]). CONCLUSIONS: In this large multi-ethnic US sample, receipt of safe sleep mHealth messaging was associated with lower rates of bedsharing without negatively impacting breastfeeding rates. Future research should focus on continued development of interventions to improve adherence to both safe sleep and breastfeeding recommendations.

Risk of Postneonatal Infant Mortality Associated With Prior Founded Allegations of Child Abuse.

This study examined the association between prior reports of child abuse and subsequent postneonatal death and differences by cause of death, using data from the Chicago Infant Mortality Study (CIMS). CIMS included all sudden, unexplained infant deaths up to 1 year of age in Chicago (November 1993-April 1996), and age, race-ethnicity, and birthweight-matched living controls. Information on prior child abuse reports and outcomes was obtained through the Illinois Department of Children and Family Services (DCFS) State Central Registry for each case and control. Conditional logistic regression modeling determined the odds of postneonatal death when there was a founded prior allegation. Families with founded allegations were almost 4 times more likely to have a child die during the postneonatal period (aOR = 3.79, 95% CI, 1.56, 9.10). Child protective services involvement is an opportunity for education on safe sleep messaging to help reduce the incidence of potentially preventable infant deaths.

Explaining Sudden Unexpected Infant Deaths, 2011-2017.

BACKGROUND: Sudden unexpected infant death (SUID) represents a broad group of explained and unexplained infant deaths (<1 year old). Explaining why SUID occurs is critical to understanding etiology and prevention. Death certificate data cannot differentiate explained from unexplained SUID cases nor describe the surrounding circumstances. We report SUID rates by explained and unexplained categories and describe demographics and history of recent injury or illness using the Centers for Disease Control and Prevention SUID Case Registry. METHODS: The registry is a population-based surveillance system built on Child Death Review programs. Data are derived from multiple sources, including death certificates, scene investigations, and autopsy reports. Cases included SUIDs reported by states or jurisdictions participating in the registry during 2011-2017. Cases were classified into explained and unexplained categories by using the registry's classification system. Frequencies, percentages, and mortality rates per 100 000 live births were calculated. RESULTS: Of the 4929 SUID cases, 82% were categorized as unexplained. Among all cases, 73% had complete case information. Most SUIDs (72%) occurred in an unsafe sleep environment. The SUID mortality rate was 97.3 per 100 000 live births. Among explained and possible suffocation deaths, ∼75% resulted from airway obstruction attributed to soft bedding. CONCLUSIONS: Unsafe sleep factors were common in explained and unexplained SUID cases, but deaths could only be classified as explained suffocation for ∼20% of cases. Further analysis of unexplained deaths, including continued improvements to death scene investigation and documentation, may generate hypotheses for physiologic and genetic research, advance our understanding of gaps in SUID investigation, and enhance our understanding of infants at highest risk.