A Multicomponent Intervention to Train and Support Family Medicine Providers to Promote Pre-exposure Prophylaxis (PrEP) for Adolescent Girls and Young Women in the Deep South: Protocol for the PrEP-Pro Study.

BACKGROUND: Pre-exposure prophylaxis (PrEP) is a highly effective biomedical prevention intervention and a major strategy for reducing the HIV burden in the United States. However, PrEP provision and uptake remain lower than estimated needs, and in ways that may exacerbate HIV disparities among Black adolescent girls and young women in the southern United States. Data suggest that gaps in provider knowledge of HIV epidemiology and PrEP and skills assessing sexual health practices are important barriers to provision and uptake, with limited evidence-based interventions to address these gaps. OBJECTIVE: This paper describes the "PrEP-Pro" intervention, a multicomponent intervention to train and support family medicine (FM) trainees to promote PrEP for adolescent girls and young women in Alabama. METHODS: The PrEP-Pro intervention comprises 3 main components guided by the Capability-Opportunity-Motivation-Behavior (COM-B) model for behavioral change and the Consolidated Framework for Implementation Research (CFIR): (1) provider HIV epidemiology and PrEP education, (2) sexual history taking, and (3) PrEP Champions. In phase 1, we will work with community advisory boards (providers and clients) and then conduct focus groups with FM trainees to adapt content to train FM residents on HIV epidemiology and PrEP and develop implementation strategies, including provider-facing tools and client-facing educational materials. In phase 2, we will pretest and then pilot-test the initially adapted PrEP-Pro intervention with FM trainees. FM trainees will complete baseline, 3-, and 6-month questionnaires post PrEP-Pro intervention. We will also conduct in-depth interviews (IDIs) with FM pilot participants, adolescent girls and young women who accessed care after the PrEP-Pro pilot, and key stakeholders. The primary outcomes are PrEP-Pro acceptability and feasibility, which would be assessed using validated instruments at months 3 (among pretest participants) and 6 (among pilot participants). Secondary outcomes will also be assessed, including PrEP knowledge, sexual history-taking attitudes and practices, PrEP prescriptions among adolescent girls and young women encounters, and sexually transmitted infections (STIs) and HIV testing among adolescent girls and young women encounters in 6 months. RESULTS: Study results will be disseminated to practices, state health officials, and other key stakeholders to solicit feedback on implementation opportunities and challenges to inform a hybrid effectiveness implementation trial. Our results will also be presented at local and national conferences and submitted to peer-reviewed journals. CONCLUSIONS: As PrEP grows, there is a pressing need to train FM providers and develop appropriate, contextually relevant tools to support PrEP implementation. The PrEP-Pro intervention is a multicomponent intervention to train FM residents across Alabama on sexual history-taking, PrEP provision for adolescent girls and young women, and supporting practice-based PrEP Champions. The PrEP-Pro intervention is anticipated to increase PrEP prescriptions for adolescent girls and young women and expand comprehensive sexual and reproductive health care for adolescent girls and young women in rural and urban Alabama. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/44908.

Getting to the Sandbar: Understanding the Emotional Phases of COVID-19 Among College and University Students.

This paper provides a framework for understanding the emotional and behavioral responses of college and university students during the COVID-19 pandemic. It builds on the Substance Abuse and Mental Health Services Administration (SAMHSA) Phases of Disaster Model and Maslow's Hierarchy of Needs. Additionally, we conceptualize a new phase in the Phases of Disaster Model, which we refer to as the "Sandbar Phase," to address the unique factors of COVID-19 for college and university students. For each phase, we discuss the expected timeline and the associated emotional reactions, behaviors, and applications of Maslow's Hierarchy of Needs during COVID-19 for college and university students. Our proposed model aims to reveal short- and long-term effects of COVID-19 on the mental health of college and university students and be a resource in the development of effective mitigation efforts to diminish any psychological deficits as the result of future disasters and/or traumatic events.

Reducing the African American HIV Disease Burden in the Deep South: Addressing the Role of Faith and Spirituality.

Nearly half of HIV infections in the United States are concentrated among African Americans, and over half of new HIV infections occur in the South. African Americans have poorer outcomes in the entire continua of HIV and PrEP care. Complex social, structural, and behavioral factors contribute to our nation's alarming racial disparities in HIV infection, particularly in the Deep South. Despite the importance of faith, spirituality and religious practice in the lives of many African Americans, there has been little scientific investment exploring how African Americans' religious participation, faith and spirituality may impact our nation's HIV epidemic. This article summarizes the state of the science on this critical issue. We also identify opportunities for new scholarship on how faith, spirituality and religious participation may impact HIV care continuum outcomes in the South and call for greater federal research investment on these issues.

Effective mentoring of underrepresented doctoral trainees and early career scholars in the biobehavioral and health sciences: A developmental framework to maximize professional growth.

Effective mentoring of underrepresented scholars in the biobehavioral and health sciences is vital for the future of scientific inquiry, as well as for clinical and public health applications. Through the mentoring process, both the mentee and mentor can benefit by broadening their knowledge, skills, and perspectives relative to the professional goals and interests of the mentee. Establishing a trusting and nurturing relationship allows the mentor and mentee to identify short- and long-term goals, accompanied by strategies designed to maximize the mentee's success. Many relationships benefit from establishing explicit working guidelines early on, with recognition that flexibility may be necessary as the relationship matures. Adapting to the specific needs and challenges facing underrepresented doctoral trainees and early career scholars, we propose an integrative developmental framework informed by 3 fundamental assumptions: (a) the mentee's professional growth and personal development are intertwined; (b) the mentee's goals will evolve and sometimes change over time; and (c) reflective analysis of the distinctive skill sets, life experiences, and limits of the mentor and mentee will help strengthen the mentoring plan. A challenging issue in mentoring is how to individualize the approach for each mentee, recognizing the need to balance mentor support and advice with opportunities for mentee independence, self-appraisal, and creativity. We share our developmental framework with the hope that others may adapt this as a practical template to develop a joint plan amenable to intermittent monitoring to optimize productivity and personally rewarding professional career trajectories for an increasingly diverse workforce. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Barriers to HIV Testing: Patient and Provider Perspectives in the Deep South.

Although CDC guidelines call for universal, "opt-out" HIV testing, barriers to testing continue to exist throughout the United States, with the rural South particularly vulnerable to both HIV infection and decreased awareness of status. Therefore, the objectives of this study were to evaluate uptake of "opt-out" HIV testing and barriers to testing within the primary care setting in the South. A concurrent triangulation design guided the collection of quantitative data from patients (N = 250) and qualitative data from providers (N = 10) across three primary health clinics in Alabama. We found that 30% of patients had never been tested for HIV, with the highest ranked barrier among patients being perceived costs, access to specialty care, and not feeling at risk. Significant differences existed in perceived barriers between patients and providers. Increased provider-patient engagement and the routine implementation of "opt-out" HIV testing would effectively reveal and mitigate barriers to testing, thus, increasing awareness of status.

Risk, resilience, and depressive symptoms in low-income African American fathers.

OBJECTIVE: Parental depression influences family health but research on low-income African American fathers is limited. The primary goal of the present study was to examine the role of paternal risk factors and resilience resources in predicting depressive symptoms in the year after birth of a child in a sample of African American fathers. We hypothesized that paternal risk factors (low socioeconomic status [SES], perceived stress, negative life events, racism, avoidant coping style) and resources (social support, self-esteem, collective efficacy, approach-oriented coping style) would predict depressive symptoms in fathers at 1 year postbirth controlling for depressive symptoms at 1 month postbirth. METHOD: African American fathers (n = 296) of predominantly low SES from 5 U.S. regions were interviewed at 1 and 12 months after birth of a child regarding potential risk factors, resilience resources, and depressive symptoms. RESULTS: Depressive symptoms were low on average. However, hierarchical linear regression analyses revealed that avoidant coping style and experiences of racism predicted more depressive symptoms in fathers nearly a year after the birth of a child controlling for symptoms at 1 month. CONCLUSIONS: How fathers cope with stress and common everyday experiences of racism contributed to depressive symptoms in the year following birth of a child. Interventions that target race-related stressors and decrease avoidant coping may promote better outcomes in this important and understudied population. (PsycINFO Database Record

Issues and Solutions for Collecting Biological Specimen in Longitudinal Studies: Experience from the Community Child Health Network Research Network.

The inclusion of biomarkers in studies of stress and health outcomes is of growing interest, including for community-based participatory research (CBPR) studies. Yet the perspectives of participants and communities have been infrequently consulted to inform the biomarker collection process. The objective of this paper is to describe the process and outcomes of using CBPR in framing biomarker collection in a study of allostatic load in a maternal and child health population. Through analysis of focus group data, we identify aspects of CBPR that facilitate increased community trust and endorsement related to collecting biological samples, and also provide a community perspective that is often overlooked in the literature. We found that a CBPR approach facilitated greater understanding among community members about the importance of biomarkers, while simultaneously informing the design of a biomarker data collection protocol that was responsive to the desired scope and data collection procedures that reflected community priorities.

The Community Child Health Network Life Stress Interview: a brief chronic stress measure for community health research.

BACKGROUND AND OBJECTIVES: Chronic stress is implicated in many theories as a contributor to a wide range of physical and mental health problems. The current study describes the development of a chronic stress measure that was based on the UCLA Life Stress Interview (LSI) and adapted in collaboration with community partners for use in a large community health study of low-income, ethnically diverse parents of infants in the USA (Community Child Health Network [CCHN]). We describe the instrument, its purpose and adaptations, implementation, and results of a reliability study in a subsample of the larger study cohort. DESIGN AND METHODS: Interviews with 272 mothers were included in the present study. Chronic stress was assessed using the CCHN LSI, an instrument designed for administration by trained community interviewers to assess four domains of chronic stress, each rated by interviewers. RESULTS: Significant correlations ranging from small to moderate in size between chronic stress scores on this measure, other measures of stress, biomarkers of allostatic load, and mental health provide initial evidence of construct and concurrent validity. Reliability data for interviewer ratings are also provided. CONCLUSIONS: This relatively brief interview (15 minutes) is available for use and may be a valuable tool for researchers seeking to measure chronic stress reliably and validly in future studies with time constraints.

Maternal depression and rapid subsequent pregnancy among first time mothers.

PURPOSE: To examine differences in prenatal depression among first-time mothers who had a subsequent pregnancy within 6 months of first birth and those who did not. Mothers with depression symptoms were expected to have a greater likelihood of rapid subsequent pregnancy. STUDY DESIGN: The Parenting for the First Time study is a longitudinal multisite prospective descriptive study designed to identify and understand the dynamics of subthreshold neglectful parenting behaviors among first-time mothers. Data were collected from the prenatal period through the child's first 3 years of life. The Parenting for the First Time sample consisted of 684 first-time mothers between 15 and 36 years. Data were available on prenatal depression and subsequent pregnancy at 6 months for 279 participants (n = 279). METHODS: Multiple logistic regression analysis was conducted to determine the odds of subsequent pregnancy within 6 months of first birth. RESULTS: Twelve mothers (5.9%) became pregnant within 6 months of first birth. The odds of subsequent pregnancy were 7.24 greater (95% confidence interval [CI]: 2.18-24.04) among mothers with moderate-to-severe depression. White versus non-White race did not influence subsequent pregnancy (0.91, 95% CI: 0.18-4.49). Pregnancy was not significantly different between teen and adult mothers (odds ratio: 0.92, 95% CI: 0.24-3.68). CLINICAL IMPLICATIONS: In this sample of first time mothers, moderate-to-severe depression symptoms were associated with subsequent pregnancy within 6 months of first birth. Routine depression screening by nurses during the prenatal period offers opportunities for intensive contraceptive counseling and may help mothers achieve optimal birth spacing.

Shedding Light on the Mechanisms Underlying Health Disparities Through Community Participatory Methods: The Stress Pathway.

Health disparities are large and persistent gaps in the rates of disease and death between racial/ethnic and socioeconomic status subgroups in the population. Stress is a major pathway hypothesized to explain such disparities. The Eunice Kennedy Shriver National Institute of Child Health and Human Development formed a community/research collaborative-the Community Child Health Network-to investigate disparities in maternal and child health in five high-risk communities. Using community participation methods, we enrolled a large cohort of African American/Black, Latino/Hispanic, and non-Hispanic/White mothers and fathers of newborns at the time of birth and followed them over 2 years. A majority had household incomes near or below the federal poverty level. Home interviews yielded detailed information regarding multiple types of stress such as major life events and many forms of chronic stress including racism. Several forms of stress varied markedly by racial/ethnic group and income, with decreasing stress as income increased among Caucasians but not among African Americans; other forms of stress varied by race/ethnicity or poverty alone. We conclude that greater sophistication in studying the many forms of stress and community partnership is necessary to uncover the mechanisms underlying health disparities in poor and ethnic-minority families and to implement community health interventions.

The parenting responsibility and emotional preparedness (PREP) screening tool: a 3-item screen that identifies teen mothers at high risk for nonoptimal parenting.

OBJECTIVE To test the ability of a 3-item screening tool (Parenting Responsibility and Emotional Preparedness [PREP]) to detect adolescent mothers at elevated risk for nonoptimal parenting and poor child development outcomes at 2 years of age. DESIGN A 4-site prospective cohort study conducted from December 2001 to August 2007 of adolescent mothers recruited in the third trimester of pregnancy and followed up at 4, 8, 18, and 24 months post partum. SETTING Community clinics and home settings in Birmingham, Alabama; Kansas City, Kansas and Missouri; South Bend, Indiana; and Washington, DC. PARTICIPANTS A total of 270 first-time adolescent mothers (aged 15-19 years) and their infants (birth to 2 years of age). MAIN EXPOSURES Naturalistic observations of parent-child interactions and quality of home environment during the first 2 years of life. OUTCOME MEASURES Maternal mental health and cognitive indicators, positive mother-child interactions, quality of home environment, child social-emotional development, and child cognitive development (Bayley scales). RESULTS PREP scores identified adolescent mothers with significantly elevated depressive symptoms and childhood trauma and lower scores of knowledge of infant development and maternal IQ. PREP predicted significantly lower quality of home environments and higher levels of nonoptimal mother-child interactions at 4, 8, and 18 months. PREP also predicted significantly lower child outcomes at 2 years of age for cognitive scores and higher levels of depressive and withdrawal symptoms and dysregulation and negative emotionality. CONCLUSIONS PREP is a low-cost, easily administered, nonstigmatizing screening tool that identifies adolescent mothers who self-recognize that they need help to meet their infants' social, emotional, and cognitive needs.

Pregnancy intentions, long-acting contraceptive use, and rapid subsequent pregnancies among adolescent and adult first-time mothers.

PROBLEM: Greater understanding is needed related to qualitatively assess pregnancy intentions and rapid subsequent pregnancies among adolescent and adult mothers. METHODS: Four-site prospective study of 227 adolescent and adult mothers. Data were analyzed to understand the relationship between pregnancy intentions, adolescent status, and use of long-acting contraceptives and rapid subsequent pregnancy. FINDINGS: The findings from this study provide evidence of the importance of goal-oriented pregnancy intentions, long-acting contraceptive use, and older age in delaying a second pregnancy. CONCLUSION: Findings reveal the need for clinician awareness of the qualitative pregnancy intentions of young women and potential desired use of long-acting contraceptives.

Depression among a sample of first-time adolescent and adult mothers.

PROBLEM: Little is known about the rates, correlates, and consequences of depression among a sample of first-time mothers. METHODS: Four-site prospective study of the first 3 years of life among first children born to first-time mothers, including adolescent (N= 396), lower- (N= 169), and higher-resource adult (N= 117). Mothers were administered the Beck Depression Inventory prenatally and 6 months postpartum. Measures of maternal and infant behaviors were taken at 8 months. FINDINGS: Adolescent mothers displayed higher prenatal and 6-month rates of depression than lower- and higher-resource adult mothers, with significantly more adolescent mothers "consistently" depressed at the two time points than lower- and higher-resource adult mothers. Further, adolescent mothers were significantly more likely to become depressed after their babies were born than lower- or higher-resource adult mothers. Depression was negatively related to parenting practices and babies' behavior. As depression increased, mothers scored less favorably in maternal warmth and sensitivity, contingent responsiveness, and general verbalness; children scored less favorably in warmth seeking toward their mothers. CONCLUSION: Findings signify the need for counseling and nurse-based intervention and prevention services geared at preparing pregnant adolescents for motherhood.

The Influence of Maternal History of Abuse on Parenting Knowledge and Behavior.

This study examined the intergenerational transmission of abuse among a sample of 681 teen, adult low, and adult high resource first-time mothers. Participants ranged in age from 14 to 36 years, with a mean of 20 years. Exposure to childhood emotional and physical abuse was associated with 6-month parenting behavior; but not parenting knowledge. Teen mothers, as opposed to adult mothers, had higher mean scores for exposure to childhood emotional and physical abuse. Adult high resource mothers reported lower mean scores on each abuse outcome than both teen and adult low resource mothers. For the total sample of mothers, as past exposure to emotional and physical abuse increased, maternal responsivity decreased, and opinions towards, and propensities for, abusive behavior increased.

Cell phones and the measurement of child neglect: the validity of the parent-child activities interview.

Two multisite studies were conducted to assess the feasibility of using cell phone interviews (the Parent-Child Activities Interview) to learn more about the quality of daily parenting among high-risk mothers, including child neglect. In Study 1, 45 primiparous teenage mothers with 3- to 9-month-old infants were recruited and randomly assigned to two groups: one received frequent cell phone interviews and the other group less frequent interviews over their home telephone. Relationships among paper-and-pencil surveys of parenting (gathered in person) and a Parenting Essentials score (coded from the phone interviews) were significantly correlated. In Study 2, adolescent and adult mothers and their first-born children ( n = 544) completed 2 observations of parenting in their home as well as a series of 3 PCA calls at ages 4 and 8 months. Parenting Essentials coded from the interviews were significantly related to observed measures of parenting at both time points. The Parent-Child Activities Interview shows promise as a reliable and valid measure of parenting, capturing frequent and detailed information about daily parenting practices. Cell phones may prove useful in intervening with mothers at risk of suboptimal parenting and child neglect.

Perceived neighborhood characteristics and problem behavior among disadvantaged children.

Using survey data from former Head Start children in the third grade from 15 sites across the nation (n = 576), this study examines the relationship between maternal subjective neighborhood attributions and their children's behavioral problems. Maternal perceptions of neighborhood characteristics were measured across five domains, including collective efficacy, barriers to services, negative neighbor affects, probability of child status attainment success, and overall neighborhood rating. Children's problem behaviors, measured with the Social Skills Rating System, includes externalizing and internalizing outcomes. Our results suggest that the worse the maternal assessments on each neighborhood construct, the greater the extent of children's problem behavior, holding constant child demographic factors and parental socioeconomic status. In addition, we find that family income effects on children's problem behavior are partially mediated by these perceived neighborhood domains. Taken together, these results suggest that neighborhood deprivation is related to problematic behavioral outcomes in children.