An incentive-based text-messaging intervention to reduce maternal alcohol use during pregnancy and lactation in South Africa (MaRISA study): Findings from a single-arm pilot study.

BACKGROUND: South Africa has the highest rate of fetal alcohol spectrum disorders (FASD) globally. As with alcohol use during pregnancy, alcohol consumption while breastfeeding adversely impacts infant development. We pilot tested an incentive-based text-messaging intervention to reduce alcohol use during pregnancy and lactation in South Africa. METHODS: A single-arm pilot trial was conducted over 3 months in healthcare facilities in Cape Town, South Africa. Pregnant and breastfeeding participants tested positive for recent alcohol use by urinalysis. The three-month intervention had two components, contingency management of alcohol abstinence confirmed by urinalysis twice weekly and weekly health-related text messaging from an evidence-based brief intervention. We collected twice weekly urine samples for measurement of ethyl glucuronide (EtG), an alcohol biomarker, and measures of self-reported alcohol and drug use, violence exposure, and mental health at six weeks and three months post-enrollment. RESULTS: Sixty participants were enrolled, of whom 31 were pregnant and 29 lactating. The number of days with four or more drinks in the past month decreased from 9 days at baseline, on average, to 1-3 days (p-value range: 0.144-0.010) at follow-up timepoints. There were statistically significant increases in the proportions of participants with alcohol-negative urine tests (p < 0.001). The percentages of participants breastfeeding while using alcohol decreased from baseline to the end of 3 months in the overall sample and among those enrolled postpartum, though these were not significant (p-value range: 0.255-0.147). Maternal depression scores also decreased among participants enrolled postpartum (p = 0.054). Emotional abuse by the main partner, but neither physical nor sexual abuse, significantly decreased at both follow-ups in the overall sample (p = 0.032) and among participants enrolled while pregnant (p = 0.015). CONCLUSIONS: This study is among the first to pilot test an incentive-based text-messaging intervention for maternal alcohol use and other outcomes such as depression and violence exposure. Further testing is warranted in a well-powered, randomized controlled trial.

Perceptions of perinatal alcohol use and treatment needs in Cape Town, South Africa: a qualitative study.

Background: South Africa has one of the world's highest rates of foetal alcohol spectrum disorders (FASD). Recent evidence also showed that alcohol use during lactation significantly compromises child development in children exposed to alcohol through breastfeeding, independent of prenatal alcohol exposure. This study explored perceptions of perinatal alcohol use and treatment needs in Cape Town, South Africa, to inform the development of an intervention to encourage alcohol abstinence during pregnancy and breastfeeding. Methods: Individual in-depth interviews (IDIs) were conducted with women who were pregnant with a recent history of alcohol use (n=32) and clinic and community stakeholders (n=16). Interviews were audio recorded and transcribed verbatim. Coding and thematic analyses were conducted in NVivo 12. Results: Results indicate widespread perception that women know the dangers of drinking alcohol while pregnant with much less known about drinking while breastfeeding. Mixed views were shared about whether women who are pregnant or breastfeeding experience alcohol-related stigma. Participants described contextual factors impacting drinking that include interpersonal violence, lack of support, stress, anxiety and poverty, and drinking being normalised. Finally, participants had mixed views and conflicting knowledge of available resources to support alcohol reduction and highlighted a desire for support groups and the involvement of partners in alcohol interventions. Conclusions: Findings from this study highlight the need for an alcohol intervention programme that is innovative and tailored to the needs of women who are pregnant or postpartum. It also highlights the importance of including community-based support and partner involvement in these interventions.

HIV-related risk among justice-involved young African American women in the U.S. South.

Incarceration rates have increased exponentially among women, and racial disparities in justice involvement persist. Coupled with disparities in HIV in the US South that begin early in the life course, it is important to explicate the relationship between justice involvement, HIV-related risk (such as illicit drug use and sexual risk), and service needs for young African American women. This study examined the association of previous arrest, biological and self-reported HIV-related risk, and reported service needs at baseline among 646 African American women aged 18 to 25 who were recruited as part of an HIV-risk reduction trial. Approximately 24% of participants reported previously being arrested. In adjusted analyses, several substance use and sexual risk variables were found to be significant, including increased odds of positive screens for both cocaine (AOR: 3.09; 95% CI [1.49, 6.41]) and marijuana (AOR: 1.82; 95% CI [1.17, 2.83]), trading sex for goods (AOR: 2.23; 95% CI [1.14, 4.38]), and recent sexually transmitted infections (AOR: 1.84; 95% CI [1.03, 3.27]). Previous arrest was associated with greater service needs, including violence-related (AOR: 4.42; 95% CI [2.03, 9.64]), parenting (AOR: 2.92; 95 CI% [1.65, 5.17]), and housing (AOR: 2.38; 95% CI [1.54, 3.67)]). The study findings indicate the increased risk across both HIV-related substance use and sexual risk and the service needs for African American women in emerging adulthood who have been arrested. These disparities suggest the importance of interventions to address the specific needs of this population at a critical period to not only prevent HIV but also address social determinants.

Teaching antenatal hand expression: a feasibility study in an inner urban U.S. hospital.

BACKGROUND: Many women have low confidence in breastfeeding and have concerns regarding low milk volume or discomfort with breastfeeding. Antenatal hand expression may be an opportunity to help women feel more comfortable with breastfeeding and help promote exclusive breastfeeding. A study at a hospital in Philadelphia, Pennsylvania, U.S. assessed the feasibility of teaching antenatal hand expression at 39 weeks among socioeconomically disadvantaged populations, overall participant satisfaction and adoption of hand expression and breastfeeding. METHODS: From March 2020 to June 2021, women recruited at 34-39 weeks were taught to hand express, collect, and store colostrum. Starting from 39 weeks, participants were asked to practice hand expression 1-3 times / day until delivery, log their experiences, and store colostrum expressed. Women were contacted to encourage continued hand expression and answer any questions. Postpartum, a survey assessed satisfaction with hand expression and issues encountered. The survey also inquired about breastfeeding plans and barriers, and whether women were exclusively breastfeeding (defined as infants who received only breastmilk from the time of birth). Chart review of postpartum or well-baby visit notes determined whether women continued breastfeeding. RESULTS: Of the 29 participants, 72% (21/29) reported hand expressing at home, and no women reported contractions when hand expressing. Participants rated mean satisfaction of 8.1/10 (SD = 1.62) with antenatal hand expression, mean satisfaction of 9.4/10 (SD = 0.90) toward hand expression education, mean likelihood of 9.4/10 (SD = 1.24) recommending hand expression to others, and a mean score of 8.1/10 (SD = 1.69) on how helpful hand expression was in breastfeeding initiation. 90% (26/29) of women initiated breastfeeding after birth and 72% (21/29) exclusively breastfed on discharge, but only 11/29 (38%) continued exclusively breastfeeding when re-assessed 4-6 weeks postpartum. Barriers included maternal discomfort, low milk supply, and maternal or infant illness. CONCLUSIONS: This study suggests that women in an urban setting would be willing to practice antenatal hand expression. A larger and adequately powered study could be feasible to determine associations between antenatal hand expression and breastfeeding rates and confidence.

Usability and acceptability testing of a Plan of Safe Care in a mobile health platform.

Purpose: Women who are pregnant or parenting while recovering from substance use disorder (SUD) are at risk for insufficient recovery support. With the federal mandate, implementation has been left to each state for the Plan of Safe Care (POSC), leading to challenges in providing comprehensive care coordination and meeting federal reporting requirements. Methods: This research tests the usability and acceptability of a POSC platform, called SAFE4BOTH, which combines a mobile health (mHealth) app for use by mothers with substance use disorder (MSUD) with a web-based case management system for use by stakeholders to reduce the issue of fragmented postnatal maternal and infant care. The platform was designed to enable access to services, improve reporting task workflow, and assist in improving interactions between mothers and service providers.After applying a user-centered design approach, the usability and acceptability of the SAFE4BOTH platform were evaluated using focus groups, interviews, and a System Usability Scale (SUS). The evaluation involved four staff members from a Medication for Addiction Treatment clinic (comprising of three case management workers and one peer counselor), four state employees of the Delaware Division of Family Services, and 20 mothers with MSUD who had delivered infants in need of a POSC.Features tested in the SAFE4BOTH platform included a secure, web-based POSC, a contingency management-based reward system, a micro-learning library, a resources locator, a chat messaging and videoconferencing system, a directory for contact management, a QR code reader, use of an appointment compliance system engaging geofencing, and an enhanced calendar. Family services and treatment center staff accessed SAFE4BOTH from their laptops or tablets, and MSUD accessed SAFE4BOTH from their phones. Results: Family services staff, treatment center staff, and MSUD participants rated SAFE4BOTH as usable and acceptable with average System Usability Scale scores of 68.1 (SD 8.5), 92.5 (SD 11.73), and 78.4 (SD 12.5) (respectively). Conclusion: The platform was judged both usable and acceptable by all three target populations (family services staff, treatment center staff, and MSUD). Further studies are planned to explore the efficacy of longitudinally supporting the mother's recovery and the infant's healthy development.

The Association of Maternal Smoking and Drinking Changes During Pregnancy and Postpartum Breastfeeding Pattern and Duration.

Objectives: To conduct a secondary data analysis of how changes in smoking and drinking during pregnancy impact status of any breastfeeding and breastfeeding duration in a national cohort. Materials and Methods: A cross-sectional study was conducted using Pregnancy Risk Assessment Monitoring System (PRAMS) data between 2009 and 2017 (n = 334,203). Univariate and multivariate analyses were conducted on the status of any breastfeeding and breastfeeding duration. Results: A dose-dependent inverse relationship was found in which women who smoked the same or more or resumed smoking during pregnancy showed the lowest likelihood and shortest duration of breastfeeding, followed by reduced smokers, quitters, and nonsmokers. Women with a history of alcohol use were significantly more likely to breastfeed compared with women without a history of alcohol use. Conclusions: The profile of smoking change during pregnancy impacts the likelihood and duration of breastfeeding in a dose-dependent and inverse manner. No such relationship was found with drinking change during pregnancy. Public Health Implications: Significant public health efforts should focus on implementing and sustaining evidence-based interventions for prenatal smoking cessation and educating providers and maternal populations on the adverse effect of postpartum alcohol exposure.

A training curriculum for an mHealth supported peer counseling program to promote exclusive breastfeeding in rural India.

BACKGROUND: Despite strong evidence about the benefits of exclusive breastfeeding, that is the baby receiving only breast milk, no other foods or liquids, rates have remained relatively unchanged over the past two decades in low- and middle-income countries. One strategy for increasing exclusive breastfeeding is through community-based programs that use peer counselors for education and support. The use of mobile health applications is also gaining increasing applicability in these countries. Minimal information is available about training peer counselors in the use of mobile technologies to support exclusive breastfeeding. The present article describes our curriculum in the state of Karnataka, India for supporting new mothers to exclusively breastfeed using a mobile health application in rural India. METHODS: Twenty-five women from the community surrounding the city of Belgavi, Karnataka, India were trained to be peer counselors and to use a mobile health application to conduct a structured curriculum to support new mothers in exclusive breastfeeding. The three-day interactive training, conducted in March 2018, was based on the WHO breastfeeding course, translated, and adapted to the local culture The curriculum, which included information collected during a formative research process, consisted of eight visits, two during the antenatal period and continuing for six months postpartum. Twelve nursing and obstetric experts validated curriculum content. Pre-post-evaluation of the training focused on breastfeeding knowledge, self-efficacy, skills, and app usability. RESULTS: We observed a significant increase in the mean scores for knowledge (P < 0.0001) and skills (P = 0.0006) from pre- to post-training. Age of the peer counselors and their own breastfeeding experience correlated significantly with the acquisition of knowledge and skills. The mobile health app showed high usability scores. CONCLUSIONS: The culturally adapted curriculum presented here, combined with an mHealth app, can be an important educational strategy for training rural women in the acquisition of exclusive breastfeeding knowledge and skills.

Emerging Opportunities to Improve Treatment Access for Substance Use Disorders and Other Comorbid Health Issues Among Women Enrolled in WIC.

Women living in underserved communities are at an increased risk for substance use disorders and other comorbid health issues, a public health concern that was exacerbated as the COVID-19 pandemic took hold. In response to the challenges the pandemic presented, services delivered by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) adapted nimbly, including WIC nutrition managers' and counselors' efforts to provide reactive referrals of clients raising concern about substance misuse and related consequences. This adaptation signaled an opportunity to consider integrating more proactive, evidence-based strategies for substance use disorders such as standardized brief assessments, advice, and referral procedures (i.e., Screening, Brief Interventions, and Referral to Treatment [SBIRT]), as part of routine WIC operations. Integration of such routine practice would improve the quality of care WIC provides to their clients and families, while addressing a major gap in public health by connecting clients at high risk for substance use disorders and substance-related problems to much needed services. Given the adaptability of WIC to reactively manage the wide array of psychosocial and mental health problems that increased during the pandemic, opportunities exist for future research to examine the feasibility, acceptability, and efficacy of proactive implementation of brief screening, advice, and treatment referral to reduce substance-related harm among women living in underserved communities.

A cluster analysis of mothers of reproductive age based on their attitude and risk of alcohol use.

The rates of alcohol use and binge drinking are increasing among women. To examine factors that can differentiate women with low-risk alcohol use from those with high-risk alcohol use, the present study explored whether there would be distinct subgroups of mothers who differed in their attitudes and risk of alcohol use. A sample of 141 women aged between 18 and 50 years old who had given birth within 3 years was recruited on Amazon Mechanical Turk. A hierarchical cluster analysis was conducted to categorize the mothers based on the similarities between their attitudes and risk of alcohol use, which resulted in the identification of the following distinct subgroups: (a) mothers with negative attitudes toward alcohol use and low risk for problematic alcohol use, (b) mothers with positive attitudes and low risk, and (c) mothers with positive attitudes and high risk. These subgroups of mothers were then compared on the extent to which they differed in trait impulsivity and impulsive decision-making toward instant gratification. The results showed that the subgroups significantly differed in trait impulsivity but not in impulsive decision-making toward instant gratification. The present study demonstrated the usefulness of cluster analysis for profiling distinct, practically meaningful subgroups of mothers of reproductive age based on their attitudes and risk of alcohol use, which has important implications for developing intervention strategies for problematic alcohol use in this population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Design, Development, and Testing of BEST4Baby, an mHealth Technology to Support Exclusive Breastfeeding in India: Pilot Study.

BACKGROUND: Exclusive breastfeeding (EBF) at 6 months of age in most low- and middle-income countries, including India, is surprisingly low. There is a relative lack of mobile health apps that specifically focus on leveraging the use of peer counselors (PCs) to support mothers as a means of increasing EBF practices in low- and middle-income countries. OBJECTIVE: This study aimed to design, develop, and test the usability of Breastfeeding Education Support Tool for Baby (BEST4Baby), a mobile health app specifically designed to support PCs in providing in-home breastfeeding counseling support to mothers in rural India on optimal breastfeeding practices. METHODS: A user-centered design process with an agile development methodology was used. The approach involved stakeholders and mothers who were trained to serve as PCs to guide BEST4Baby's design and development, including the app's content and features. PCs were engaged through focus groups with interactive wireframes. During the 24-month pilot study period, we conducted a feasibility test of the BEST4Baby app with 22 PCs who supported home visits with mothers residing in rural India. The intervention protocol required PCs to provide education and follow mothers using the BEST4Baby app, with 9 scheduled home visits from the late prenatal stage to 6 months post partum. BEST4Baby's usability from the PCs' perspective was assessed using the translated System Usability Scale (SUS). RESULTS: The findings of this study align with best practices in user-centered design (ie, understanding user experience, including context with iterative design with stakeholders) to address EBF barriers. This led to the cultural tailoring and contextual alignment of an evidence-based World Health Organization breastfeeding program with an iterative design and agile development of the BEST4Baby app. A total of 22 PCs tested and rated the BEST4Baby app as highly usable, with a mean SUS score of 85.3 (SD 9.1), placing it over the 95th percentile for SUS scores. The approach translated into a highly usable BEST4Baby app for use by PCs in breastfeeding counseling, which also statistically increased EBF practices. CONCLUSIONS: The findings suggest that BEST4Baby was highly usable and accepted by mothers serving as PCs to support other mothers in their EBF practices and led to positive outcomes in the intervention group's EBF rates. The pilot study demonstrated that using the specially designed BEST4Baby app was an important support tool for mothers to serve as PCs during the 9 home visits. TRIAL REGISTRATION: Clinicaltrials.gov NCT03533725; https://clinicaltrials.gov/ct2/show/NCT03533725.

Gender and Context Matter: Behavioral and Structural Interventions for People Who Use Alcohol and Other Drugs in Africa.

Heavy alcohol consumption and other drug use are prominent across Africa and increase the risk of exposure to violence, HIV acquisition, and other life-threatening injuries. This review synthesizes evidence on alcohol and other drug (AOD) interventions in Africa; evaluates the differences between interventions that do and do not specifically target populations that use AODs; and highlights the impact of comprehensive vs. brief interventions and those that address syndemic issues from a gender and contextualized lens. Literature searches were conducted to identify research outcomes of randomized interventions published between January 2010 and May 2022 that address AOD use in Africa. Thirty-five full-text articles were included in this review. Most of the identified research studies were concentrated in a few countries. Most studies were conducted in South Africa. Many of the studies comprised brief interventions. However, the most comprehensive interventions were the most effective for AOD outcomes. Several studies indicated the importance of addressing AOD use alongside gender-based violence, mental health needs, gender roles, and other social determinants that affect health outcomes. Intervening on AOD use and addressing social determinants from a gender and contextually relevant perspective is essential to ensuring the long-term health and well-being of people in Africa.

A Scoping Review of Computer-Based and Telecommunication Technology Interventions to Address Drug and Alcohol Misuse and Smoking in Women.

BACKGROUND: Computer-based and telecommunication technology has become increasingly common to address addiction among women. This review assessed the effect of technology-based interventions on substance misuse, alcohol use, and smoking outcomes among women. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guideline was used to conduct the scoping review. Four databases (PubMed, Web of Science, PsycINFO, and Scopus) were used to search for peer-reviewed articles published in English on computer-based and telecommunication technology use to address substance misuse, alcohol use, and smoking among women. RESULTS: A total of 30 articles were selected after the final full-text review from the U.S., England, Japan, and the Netherlands. The types of technology used in the interventions included computer software (standalone or web-based), mobile applications, video calling, phone, and text messaging. Intervention outcomes included alcohol and other substance misuse reduction as polysubstance misuse (n = 5), smoking cessation (n = 10), substance misuse reduction only (n = 6), and alcohol use reduction only (n = 9). The populations reached included women who were pregnant (n = 13), postpartum (n = 4), or non-pregnant (n = 14) ranging from adolescent to adulthood. Interventions that targeted polysubstance misuse showed statistically significant reductions (p < .05). CONCLUSION: Although effective in reducing alcohol and other substance misuse, mixed findings were identified for other outcomes targeting a single substance. Technology-based interventions might maximize their effects by targeting polysubstance misuse and addressing associated contextual issues in the form of a computer-delivered module(s).

A behavioral economic demand analysis of mothers' decision to exclusively breastfeed in the workplace.

The present study determined whether behavioral economic demand analysis could characterize mothers' decision to exclusively breastfeed in the workplace. Females, aged between 18 and 50 who have given birth in the past three years, completed a novel demand task with hypothetical scenarios, in which they returned to work with a 2-month-old baby. Participants rated their likelihood of breastfeeding their baby at a workplace lactation room versus formula-feeding their baby at their desk. The distance to the lactation room ranged from 10 s to 60 min. This assessment was conducted with and without hypothetical financial incentives for 6-month exclusive breastfeeding. Primary dependent measures were demand intensity and change in demand elasticity, which could conceptually represent initiation and continuation of breastfeeding, respectively. Demand for breastfeeding was more intense and less elastic (i.e., more likely to initiate and continue breastfeeding) among mothers with an experience of 6-month exclusive breastfeeding and under the condition with the financial incentives. The novel demand task can potentially provide a useful behavioral marker for quantifying mothers' decision to initiate and continue exclusive breastfeeding in the workplace, informing workplace policy regarding lactation rooms, identifying risk for early cessation, and developing and individualizing an intervention to assist mothers to exclusively breastfeed in the workplace.

Feasibility, acceptability, and preliminary impact of an mHealth supported breastfeeding peer counselor intervention in rural India.

OBJECTIVE: To evaluate the feasibility of an mHealth-supported breastfeeding peer counselor intervention implemented in rural India and the preliminary impact of the intervention on maternal breastfeeding behaviors, including exclusive breastfeeding (EBF). METHODS: In this quasi-experimental pilot study, participants received either the intervention plus usual care (n = 110) or usual care alone (n = 112). The intervention group received nine in-home visits during and after pregnancy from peer counselors who provided education about and support for EBF and other optimal infant feeding practices and were aided with an mHealth tool. The control group received routine prenatal and postnatal health education. Progress notes and surveys were used to assess feasibility. Logistic regression models were used for between-group comparisons of optimal infant feeding outcomes, including EBF for 6 months. RESULTS: The intervention was delivered as intended, maintained over the study period, and had high acceptability ratings. There were statistically significant differences in all outcomes between groups. The intervention group had a significantly higher likelihood of EBF at 6 months compared to the control group (adjusted odds ratio 3.57, 95% confidence interval 1.80-7.07). CONCLUSION: Integration of mHealth with community-based peer counselors to educate women about EBF is feasible and acceptable in rural India and impacts maternal breastfeeding behaviors.

Neonatal Outcomes after Combined Opioid and Nicotine Exposure in Utero: A Scoping Review.

BACKGROUND: The majority of women who are pregnant with opioid use disorder (OUD) also smoke tobacco but are rarely offered tobacco cessation counseling. While the effects of exposure to opioids and nicotine in utero are well-understood separately, understanding the impact of the combined exposure to these substances on neonatal outcomes is lacking. METHODS: A scoping review was conducted using PubMed and Scopus databases for studies addressing the combined exposure to opioids and nicotine during pregnancy published between 1 January 1980 and 9 July 2019. A total of 29 papers met the eligibility criteria for inclusion, with nine being identified as clinical trials (three from the MOTHER study) and two as secondary data analysis of clinical trial data. RESULTS: Neonatal outcomes for infants who had a combined exposure to opioids and nicotine in utero indicated a reduction in birth weight and birth length. Findings in infants exposed to both nicotine and opioids were mixed with regard to the duration of neonatal abstinence syndrome (NAS), the likelihood of treatment for NAS, doses of medicine used to treat NAS, and NAS scores when compared with infants who had opioid exposure without nicotine. CONCLUSIONS: The combined exposure to nicotine and opioids during pregnancy may lead to a reduction in neonatal birth weight and birth length and more severe NAS signs, compared with opioid use alone, but more research is necessary to identify the minimum dosage and length of nicotine exposure to accurately predict these outcomes.

Antiretroviral Therapy (ART) Adherence and Prenatal Alcohol Use among Women Who Are Pregnant with HIV in South Africa.

This brief report emphasizes the need to focus on women with HIV who are pregnant who use alcohol or other drugs. A recently completed implementation science study tested a gender-focused behavioral intervention, the Women's Health CoOp (WHC), to improve antiretroviral therapy (ART) adherence and reduce alcohol use among women with HIV. The study identified 33 participants who had a positive pregnancy test result at the baseline assessment, of whom five participants remained pregnant during the 6-month duration of the study. Of the 33 pregnant participants at the baseline assessment, 55% reported past-month alcohol use, with 27% reporting a history of physical abuse and 12% reporting a history of sexual abuse. The five women who remained pregnant at 6 months showed improved ART adherence and reduced prenatal alcohol use. The gender-focused WHC intervention shows promise as a cost-effective, sustainable, behavioral intervention to address these intersecting syndemic issues. Future research should focus on identifying the needs of women with HIV who are pregnant who use alcohol or other drugs and developing tailored evidence-based behavioral interventions such as the WHC for preventing FASD in addition to improving ART adherence in this key population of women and reducing the economic burden on society.

Current Interventions for People Living with HIV Who Use Alcohol: Why Gender Matters.

PURPOSE OF REVIEW: Alcohol is the most misused substance in the world. For people living with HIV (PLWH), alcohol misuse may impact ART adherence and viral suppression. This review of the most recently published alcohol intervention studies with PLWH examines how these studies considered gender in the samples, design, and analyses. RECENT FINDINGS: Three searches were conducted initially, and 13 intervention studies fit our criteria with alcohol outcomes. In general, most studies did not consider gender and had used small samples, and few demonstrated significant efficacy/effectiveness outcomes. Five studies considered gender in their samples or analyses and/or were woman-focused with larger samples and demonstrated significant outcomes. It is essential for women who misuse alcohol to not only be well represented in alcohol and HIV research but also for studies to consider the barriers to reaching them and their contextual demands and/or co-occurring issues that may affect participation and outcomes in intervention research.

Placebo-controlled trial of bupropion for smoking cessation in pregnant women.

BACKGROUND: Although a relatively small proportion of women who become pregnant continue to smoke cigarettes, no smoking cessation medication has been shown to be effective for this subgroup of smokers. Bupropion, a nonnicotine-based medication, is approved for the promotion of smoking cessation in nonpregnant individuals. We chose to study it in pregnant smokers because, although pregnancy increases nicotine metabolism, it does not affect the metabolism of bupropion. OBJECTIVE: We evaluated the efficacy and safety of sustained-release bupropion for smoking cessation among pregnant women. STUDY DESIGN: We conducted a multiple site, placebo-controlled, randomized clinical trial of bupropion for tobacco use among pregnant women (N=129) (clinical trial number NCT02188459). We enrolled women during the second trimester and randomly assigned them to receive 10 weeks of treatment with either bupropion or placebo, accompanied by a total of 6 smoking cessation counseling sessions (4 during treatment and 2 postpartum). The primary outcome was 7-day point prevalence smoking abstinence, confirmed with breath carbon monoxide measurements, at the end of treatment (week 10) and at week 24. Group differences were assessed as a binary abstinence outcome using a repeated measure generalized estimating equations model with a logit link. Prolonged abstinence and smoking rates were secondary outcomes. Safety measures included maternal treatment-related adverse events, gestational age, the rate of overall and spontaneous preterm births and infant birthweight and size for gestational age, head circumference, and 5-minute Apgar scores. RESULTS: There were no significant differences in the safety measures across the treatment arms and bupropion was not efficacious in promoting smoking cessation at the end of treatment (7-day point prevalence quit rates: bupropion, 11.0%; placebo, 18.5%) or week 24 (7-day point prevalence quit rates: bupropion, 9.4%; placebo, 21.5%) (P>.05). African American women and women with a lower severity of nicotine dependence had significantly higher quit rates overall and women with an opioid use disorder who were being treated with opioid agonist therapy had significantly lower quit rates overall, irrespective of the treatment group (all P values <.05). CONCLUSION: Although bupropion use was not associated with an elevated risk for pregnancy complications when initiated in the second trimester, it did not increase the likelihood of smoking cessation in this cohort of pregnant women. Because smoking is the major preventable source of poor pregnancy outcomes and psychosocial interventions have only modest beneficial effects, additional studies are needed to identify safe and efficacious smoking cessation medications for pregnant women who continue to smoke.

Systematic review on use of health incentives in U.S. to change maternal health behavior.

Use of financial incentives contingent on health outcomes has shown effective in health behavior change. Evidence-based information on the effect of incentive use for maternal health behavior change can inform whether and how to proceed with future research as well as incorporate incentive-based interventions in the existing healthcare system. This systematic literature review was conducted among prospective studies on incentive use for maternal health behavior change in a U.S. cohort according to the PRISMA methodology. Databases subject to the search included PubMed, Web of Science, PsycINFO, and EBSCOhost. Studies published in peer-reviewed journals on or before January 7, 2019, written in English, conducted in U.S., using incentives contingent on maternal health behavior change, and prospectively designed were included. Two authors independently searched titles and abstracts. An abstraction table was constructed, and the risk of bias was assessed using the GRADE approach. The review showed that incentives such as vouchers and other financial incentives were effective in improving outcomes especially related to substance use, tobacco use, and breastfeeding. Mixed evidence was found in improving treatment adherence outcomes; however the studies with randomized trials on the outcome of treatment adherence also showed low certainty. Continued improvements need to be made in implementing an incentive-based approach in the context of comprehensive treatment and routine healthcare, exploring electronic- or mobile-based implementation of the approach, and implementing the approach for a wider variety of outcomes during both prenatal and postpartum periods.

Prior Exposure to Intimate Partner Violence Associated With Less HIV Testing Among Young Women.

Low-income minority women are disproportionately represented among those living with HIV in the United States. They are also at risk for the SAVA (substance abuse, violence, and HIV/AIDS) syndemic issues. Women who have recently given birth are at high risk for substance use and intimate partner violence (IPV), and HIV testing is not routinely administered during the postpartum visit. We explored the relationship between substance use, IPV, and HIV testing among low-income young adult women attending Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federally supported nutrition program. A survey assessed substance use, relationships in particular with violence exposure, and HIV testing behavior in the past 6 months among a convenience sample of 100 women aged 18 to 30. The survey was conducted at several WIC offices in an urban setting in the Mid-Atlantic region between June and December 2015. Physical violence was the only IPV variable significantly associated (p = .022) with not being tested for HIV in the past 6 months, remaining significant even after adjusting for demographic and other significant variables (adjusted odds ratio [AOR] = 0.02; 95% confidence interval [CI] = [0.00, 0.41]). Women exposed to physical IPV or psychological IPV in the past year were significantly more likely to have ever used an illicit drug (physical IPV: 34% vs. 59%, p = .052; psychological IPV: 22% vs. 53%. p = .002). These findings between physical IPV and HIV testing history highlight the need to further understand how the context of violence affects HIV testing behaviors. Providing convenient, safe, and accessible HIV testing sites in spaces like WIC may increase HIV testing rates overall and specifically among women experiencing IPV.