Diane Abatemarco

Supplemental Material, jchc-2017-0208-File011 for Integrating childhood obesity resources into the patient-centered medical home: Provider perspectives in the United States by Samareh G Hill, Thao-Ly T Phan, George A Datto, Jobayer Hossain, Lloyd N Werk, and Diane Abatemarco in Journal of Child Health Care

BACKGROUND The opioid crisis is a public health issue, contributing to poor maternal child health outcomes. A Mindfulness Based Parenting (MBP) intervention, part of the "Practicing Safety Mindfulness Project for Mothers in Drug Treatment" (PSMDT) study, was previously tested as an intervention to mitigate stress and improve parenting domains in a sample of parenting women in treatment for substance use disorder. METHODS Qualitative data from focus groups and Mindfulness Based Parenting group teacher process notes were analyzed to understand how participants applied mindfulness to their daily lives and how mindfulness affected their relationship with their child(ren). RESULTS Thematic analyses revealed three overarching major themes: 1) Supportive Tools to Assist with Bringing Mindfulness into Daily Living; 2) Application of Embodied Tenets of Mindfulness to Perspective and Behavior and 3) Mindfulness Based Parenting and Recovery. Transference of mindfulness skills to parenting was evident through both focus group and process note data, illustrating how mindfulness behaviors were incorporated into family life. Data also revealed how tools utilized in the MBP intervention affected participant recovery. CONCLUSIONS MBP intervention shows utility in improving parenting and recovery domains. Data from this study will inform future iterations of this intervention and this contextual analysis can be used to inform other recovery programs looking to utilize mindfulness as an adjunctive treatment.

BACKGROUND Pregnant women who have substance use disorders (SUDs) are at increased risk of preterm birth, fetal mortality, and inadequate prenatal care and have higher rates of childhood trauma than their counterparts without SUDs. Doulas have been utilized with other vulnerable populations who experience trauma to increase perinatal healthcare utilization, provide emotional support, and improve birth outcomes. The objective of the current study was to examine, in women with opioid use disorder (OUD), perceptions of working with a doula in the perinatal period. METHODS Eligible participants were ≥ 18 years old, in OUD treatment, and were pregnant or recently delivered (child ≤ 3 months of age). Semi-structured interviews were used to collect tacit data on the woman's experience working with a doula during the perinatal period. All one-hour interviews were conducted over the phone and transcribed verbatim by a HIPAA compliant transcription service. Transcripts were reviewed independently by 4 coders using open coding procedures, constant comparative method of grounded theory, and inductive thematic analysis. Demographic data and history of childhood trauma information (Adverse Childhood Experiences Tool) were collected with a phone survey prior to the interview. RESULTS Participants' (N = 23) were 32.5 years of age (4.1 SD), with the majority Caucasian (71.4%), Non-Hispanic (71.4%) and Medicaid recipients (100%). Participants reported a mean of 5.61 (SD=2.93) adverse childhood experiences, indicating a significant trauma burden. Major themes uncovered in the interview transcripts revealed emotional and OUD recovery support provided by the doula and increased maternal health literacy and self-advocacy. The presence of a doula during labor/delivery reduced maternal perceptions of stigma they perceived from their healthcare providers. CONCLUSION Doula engagement was associated with perceptions of increased emotional support, health literacy and self-advocacy in maternal health among women with OUD, which is significant given this population's trauma histories. This preliminary research has significant implications for improving the health of the mother child dyad affected by maternal OUD.

BACKGROUND AND OBJECTIVES: For children with intrauterine opioid exposure (IOE), well-child care (WCC) provides an important opportunity to address medical, developmental, and psychosocial needs. We evaluated WCC adherence for this population. METHODS: In this retrospective cohort study, we used PEDSnet data from a pediatric primary care network spanning 3 states from 2011 to 2016. IOE was ascertained by using physician diagnosis codes. WCC adherence in the first year was defined as a postnatal or 1-month visit and completed 2-, 4-, 6-, 9-, and 12-month visits. WCC adherence in the second year was defined as completed 15- and 18-month visits. Gaps in WCC, defined as ≥2 missed consecutive WCC visits, were also evaluated. We used multivariable regression to test the independent effect of IOE status. RESULTS: Among 11 334 children, 236 (2.1%) had a diagnosis of IOE. Children with IOE had a median of 6 WCC visits (interquartile range 5–7), vs 8 (interquartile range 6–8) among children w...

BackgroundChild maltreatment is a significant public health issue in the United States. Yet, fewer than half of pediatricians discuss behavioral, developmental, or parenting issues with parents.ObjectiveThis paper describes the testing of bundles of tools and processes, part of a larger intervention,Practicing Safety, targeted at changing physician and staff behavior to identify families at risk for child maltreatment, provide anticipatory guidance, refer to community resources, and follow-up and track at-risk families. The intervention was implemented with 14 pediatric primary care practices throughout the United States; the study was completed in 2011.MethodsA within-subjects repeated measures pre-post follow-up design was used to evaluate the intervention. Baseline and repeated measurements of pediatric practices’ processes were collected using qualitative and quantitative methods. In total, 14 core improvement teams from across the country tested three bundles of tools (maternal...

Pediatric primary care providers play a critical role in managing obesity yet often lack the resources and support systems to provide effective care to children with obesity. The objective of this study was to identify system-level barriers to managing obesity and resources desired to better managing obesity from the perspective of pediatric primary care providers. A 64-item survey was electronically administered to 159 primary care providers from 26 practices within a large pediatric primary care network. Bivariate analyses were performed to compare survey responses based on provider and practice characteristics. Also factor analysis was conducted to determine key constructs that effect pediatric interventions for obesity. Survey response rate was 69% ( n = 109), with the majority of respondents being female (77%), physicians (67%), and without prior training in obesity management (74%). Time constraints during well visits (86%) and lack of ancillary staff (82%) were the most frequ...

Background Current pharmacologic treatment of the neonatal abstinence syndrome with morphine is associated with a lengthy duration of therapy and hospitalization. Buprenorphine may be more effective than morphine for this indication. Methods In this single-site, double-blind, double-dummy clinical trial, we randomly assigned 63 term infants (≥37 weeks of gestation) who had been exposed to opioids in utero and who had signs of the neonatal abstinence syndrome to receive either sublingual buprenorphine or oral morphine. Infants with symptoms that were not controlled with the maximum dose of opioid were treated with adjunctive phenobarbital. The primary end point was the duration of treatment for symptoms of neonatal opioid withdrawal. Secondary clinical end points were the length of hospital stay, the percentage of infants who required supplemental treatment with phenobarbital, and safety. Results The median duration of treatment was significantly shorter with buprenorphine than with ...

Background Parenting women with substance use disorder could potentially benefit from interventions designed to decrease stress and improve overall psychosocial health. In this study we assessed whether a mindfulness based parenting (MBP) intervention could be successful in decreasing general and parenting stress in a population of women who are in treatment for substance use disorder and who have infants or young children. Methods MBP participants (N = 59) attended a two-hour session once a week for 12 weeks. Within-group differences on stress outcome measures administered prior to the beginning of the MBP intervention and following the intervention period were investigated using mixed-effects linear regression models accounting for correlations arising from the repeated-measures. Scales assessed for pre-post change included the Perceived Stress Scale-10 (PSS) and the Parenting Stress Index-Short Form (PSI). Results General stress, as measured by the PSS, decreased significantly fr...

Pediatric patients seek timely access to subspecialty care within a complex delivery system while facing barriers: distance, economics, and clinician shortages. Aim We examined stakeholder perceptions about solutions to the access challenge. We engaged over 300 referring primary care pediatricians in the evaluation of Access Clinics at an academic children's hospital. Using an anonymous online survey, we asked pediatricians about their and their patients' experiences and analyzed factors that may influence referrals. Findings Referring pediatricians reported satisfaction; they provided feedback about their patients' experiences, physician communication, and referral influences. Distance from the Access Clinic does not correlate with differences in referral volume; living in areas with higher child populations and higher median income is associated with more referrals. Referring pediatricians have strong opinions about referrals, are attuned to patient experiences, and de...

Healthy People: 2010 calls for improvement in the delivery of clinical preventive services. Physicians value preventive services, yet their rates of prevention consistently fall below recommendations. This study examines the relationship between personal characteristics of internal medicine residents and their clinical prevention practices in an outpatient setting. Participants were 56 of 80 physicians (70%) in an internal medicine residency program in New Jersey. Personal characteristics (i.e., demographics, specialty orientation, attitudes toward prevention, and personal health behaviors) of the residents were collected via a self-administered survey. A 12-month retrospective chart review of 184 new doctor-patient encounters was performed to determine rates of clinical preventive services. Clinical preventive services were performed at varying rates, and differential practices specific to the patient's gender and/or age were detected for several services. Multiple regression revealed four significant predictors of overall prevention practice: clinic site, international medical graduates, generalist orientation, and self perceived health status (R(2) = 0.32). Predictors of health promotion counseling were clinic site, international medical graduates, and generalist orientation (R(2) = 0.30). While personal characteristics such as self-rated health and generalist orientation were associated with preventive practices, factors related to the office environment were also associated with increased delivery of clinical preventive services. Prevention-oriented office systems, such as "Put Prevention Into Practice," should be worthwhile considerations to increase delivery of preventive services.

To identify characteristics associated with youth bidi use. The New Jersey Youth Tobacco Survey is a self-administered school-based survey that uses a 2-stage cluster sample design to obtain a representative statewide sample; 9589 students (grades 7-12) participated. Logistic regression was used to generate an adjusted odds ratio (OR) for current bidi use for each variable, controlling for gender, race, and school grade. Higher odds for current bidi use were noted for black and Hispanic students, users of other tobacco products, and students that perceived bidis as safer than cigarettes. These results suggest specific groups that should be targeted for intervention.

To determine the agreement between 2 measures (adult vs adolescent) of current cigarette smoking among young adults. We examined data from 1007 young adults from the New Jersey Adult Tobacco Survey. The adult measure incorporates lifetime and present use, whereas the adolescent measure assesses past 30-day use. The kappa coefficient was used to determine agreement between the 2 current cigarette smoking measures. Agreement between the measures was high, but not ideal. The percent reporting smoking in the past 30 days but not 100 cigarettes in their lifetime was notably higher, and therefore agreement was lower, for black females, Hispanic males, and college students living on campus. Sole use of the adult or adolescent measure of current cigarette smoking is insufficient to document progression to regular smoking in young adults.

Despite reductions in perinatal HIV transmission, cases continue to occur. To determine factors associated with zidovudine (ZDV) receipt among HIV-infected pregnant women we merged three data sets for women in New Jersey in 1995-1997, identifying 395 HIV-infected pregnant women. Half received two arms of ZDV prophylaxis. Attendance at five or more prenatal visits was the strongest independent factor related to ZDV receipt (OR 6.37, 95% CI 3.84, 10.57). Half (49.0%) had limited prenatal care. AIDS diagnosis, race/ethnicity, and drug use were also independently related to ZDV receipt. Post hoc analysis revealed that being unmarried, Black, multiparous, having no insurance, and illegal drug use were associated with limited prenatal care. Although the U.S. has seen reductions in HIV perinatal transmission, our research showed that HIV-infected women who did not get prenatal care were less likely to receive two arms of ZDV prophylaxis. A wide public health net that brings all women into care is necessary to reduce perinatal transmission further.

Physicians play an important role in smoking cessation, especially discussing medications. This study evaluates physician characteristics associated with higher rates of discussion of smoking cessation medications. 336 primary-care physicians in New Jersey completed a cross-sectional, self-administered, mail survey including physician demographics, practice type, previous training and confidence in treating tobacco dependence, awareness of guidelines, and perceived effectiveness of treatments. Two-thirds

BackgroundHistorically, achieving a high response rate on physician surveys has been a challenging task. Given such concerns, understanding research strategies that facilitate adequate response rates is important. Primary care physician responses to a mail survey on smoking cessation are summarized by physician specialty and timing of incentive.

To describe ethnic disparities in parental confidence managing child weight-related behaviors. This was a cross-sectional survey of 59 parents of children with obesity between 4 and 7 years of age presenting to a tertiary care pediatric weight management clinic. Parents completed a validated measure assessing their confidence managing their child's weight-related behaviors (parent confidence score). Student's t-tests and linear regression analyses were used to determine parent and child characteristics associated with parent confidence score. Families were ethnically diverse with half being of Hispanic ethnicity. Mean parent confidence score was 159 (SD 66) with 71% of parents with parent confidence scores below the clinical cut-off for the measure. Parent confidence score was lower among Hispanic (mean 133, SD 67) compared to non-Hispanic parents (mean 184, SD 55, p < 0.01). Parent confidence score was most strongly associated with parental ethnicity (β = -0.39, p = 0.002, adjusted R(2) = 0.14). Parental confidence managing weight-related behaviors was low among parents of young obese children, especially those of Hispanic ethnicity. This study highlights the need to assess parental confidence in managing weight-related behaviors as part of pediatric obesity care and to provide counseling to improve parental management of weight-related behaviors in a culturally-appropriate manner.

Given the occupational risks of hazardous waste workers, this study was conducted to explore possible differences in medical surveillance practices among blue and white collar workers. Demographic and medical surveillance data were collected from 636 white collar and 206 blue collar trainees, enrolled in health and safety training courses. Overall, 4.5% of the trainees reported being ill or injured because of hazardous substances. Significant differences (P < .0001) were noted between groups; blue collar trainees were more likely to have been ill or injured. Differences also existed for medical surveillance enrollment; 32% of the white collar trainees report enrollment compared to 19% of the blue collar trainees (P = .004). This study indicates that blue collar trainees are more likely to be injured and less likely to be enrolled in medical surveillance programs. Issues of illness and injury, as well as medical surveillance enrollment, must be addressed; ensuring that all workers receive medical surveillance needed to prevent occupational illness in the hazardous waste field.

To explore social network members' role in educating African American adolescents about sexual health issues. We conducted 21 focus groups with urban African American mothers (n=51), fathers (n=18), sons (n=20), and daughters (n=36) from Allegheny County, Pennsylvania, USA, between December 2007 and March 2008. At least one biological parent (or legal guardian) and one adolescent aged 15-17 years from each family participated. Group conversations were audio-recorded, transcribed, and analyzed using directive content analysis and the constant comparison method. Two coders independently read each transcript to identify emergent themes. A broad range of people were reportedly involved in the education process. Older siblings, extended family, and peers were most commonly cited. However, unrelated adults were also described as playing important roles. Unrelated adults included the friends of an adolescent's parents and the parents of an adolescent's friends or romantic partners. Social network members were said to address three main issues: the facts about sex and sexuality, the social aspects of sexuality (e.g., appropriate dating behaviors, choosing dating partners), and promotion of family values. When educating adolescents about sex, social network members were described as playing eight functional roles, including that of a teacher, guide, challenger, confidant, shelterer, supervisor-chaperone, role model, and provider of access to reproductive health services. These roles were not mutually exclusive, meaning that social network members often assumed different roles depending on the situation. The influence of individuals who were not an adolescent's parent was highly dependent on adolescents' relationship with their parents or on their parents' comfort dealing with sexual issues. African American…