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Publication The Massachusetts public health data warehouse and the opioid epidemic: A qualitative study of perceived strengths and limitations for advancing research(2022-01-01) Evans, Elizabeth A.; Delorme, Elizabeth; Cyr, Karl D.; Geissler, Kimberly H.Due to the opioid overdose epidemic, Massachusetts created a Public Health Data Warehouse, encompassing individually-linked administrative data on most of the population as provided by more than 20 systems. As others seek to assemble and mine big data on opioid use, there is a need to consider its research utility. To identify perceived strengths and limitations of administrative big data, we collected qualitative data in 2019 from 39 stakeholders with knowledge of the Massachusetts Public Health Data Warehouse. Perceived strengths included the ability to: (1) detect new and clinically significant relationships; (2) observe treatments and services across institutional boundaries, broadening understanding of risk and protective factors, treatment outcomes, and intervention effectiveness; (3) use geographic-specific lenses for community-level health; (4) conduct rigorous “real-world” research; and (5) generate impactful findings that legitimize the scope and impacts of the opioid epidemic and answer urgent questions. Limitations included: (1) oversimplified information and imprecise measures; (2) data access and analysis challenges; (3) static records and substantial lag times; and (4) blind spots that bias or confound results, mask upstream or root causes, and contribute to incomplete understanding. Using administrative big data to conduct research on the opioid epidemic offers advantages but also has limitations which, if unrecognized, may undermine its utility. Findings can help researchers to capitalize on the advantages of big data, and avoid inappropriate uses, and aid states that are assembling big data to guide public health practice and policy.Publication Pubertal development and risk of premenstrual disorders in young adulthood(2021-01-01) Lu, Donghao; Alenaviciute, Jurate; Bjarnason, Ragnar; Valdimarsdóttir, Unnur A.; Bertone-Johnson, Elizabeth R.STUDY QUESTION Is pubertal timing associated with risk of premenstrual disorders (PMDs) in young adulthood? SUMMARY ANSWER Late pubertal development is associated with decreased premenstrual symptom burden and risk of PMDs in young adulthood. WHAT IS KNOWN ALREADY PMDs, including premenstrual syndrome and premenstrual dysphoric disorder, may begin during the teenage years. Few risk factors in early life have been identified for PMD development. STUDY DESIGN, SIZE, DURATION A prospective cohort study of 6495 female participants during 1996–2013. PARTICIPANTS/MATERIALS, SETTING, METHODS We included participants from the Growing Up Today Study (GUTS). Pubertal development was indicated by the timing of menarche, breast and pubic hair growth. Self-reported age at menarche was longitudinally assessed at enrollment (in 1996/2004 for GUTS I/II) and onwards, and classified as early (age ≤ mean − SD, 11.64 years), normative and late menarche (age ≥ mean + SD, 13.95 years). Timing of pubic hair and breast growth were assessed multiple times during follow-up via Tanner scales, and classified into early, normative and late development according to mean ± SD. Using a validated questionnaire based on the Calendar of Premenstrual Experiences, we assessed premenstrual symptoms and identified probable cases of PMDs in 2013. We examined the associations of timing of pubertal development with premenstrual symptom score and disorders using multivariable linear and logistic regressions, respectively. MAIN RESULTS AND THE ROLE OF CHANCE In 2013 (mean age = 26), 1001 (15.4%) individuals met criteria for a PMD. An inverse association was found between age at menarche and premenstrual symptom z-score (β −0.05 per year, 95% CI −0.07 to −0.03) and risk of PMDs (odds ratio (OR) 0.93 per year, 95% CI 0.88 to 0.99). Compared to individuals with normative menarche, individuals with late menarche had a lower risk of PMDs (OR 0.73, 95% CI 0.59 to 0.91), while individuals with early menarche had comparable odds (OR 0.98, 95% CI 0.81 to 1.18). Moreover, early growth of pubic hair was associated with increased premenstrual symptoms (z-score β 0.09 per year, 95% CI 0.02 to 0.17) and PMD risk (OR 1.28, 95% CI 1.04 to 1.56), independent of age at menarche. No associations were noted for breast development. LIMITATIONS, REASONS FOR CAUTION One major limitation is some misclassification of menarche due to recall. We, however, showed robust association among participants who were premenarcheal at baseline. WIDER IMPLICATIONS OF THE FINDINGS Our findings suggest that pubertal timing, particularly timing of menarche, is inversely associated with the risk of developing premenstrual symptoms in young adulthood, and that women with later menarche have significantly lower risk of PMDs. Information on PMDs should be provided to teenage girls and their parents. If these findings are confirmed in independent populations, prevention strategies and early detection programs may be considered for women with early pubertal development. STUDY FUNDING/COMPETING INTEREST(S) The work is supported by the National Institutes of Health and Swedish Research Council. TRIAL REGISTRATION NUMBER N/APublication Family Support and Readiness to Consider Smoking Cessation among Chinese and Vietnamese American Male Smokers(2021-01-01) Daniel, Joan A.; Kim-Mozeleski, Jin E.; Poudel, Krishna C.; Sun, Angela; Burke, Nancy J.; Tsoh, Janice Y.Introduction. Smoking prevalence is disproportionately high among Asian American immigrant men with limited English proficiency. Understanding the role of family support may provide insights into culturally acceptable strategies to promote smoking cessation. Aims. This study examined how family support was associated with readiness to consider smoking cessation among Chinese and Vietnamese American male daily smokers. Methods. We analyzed baseline data (N = 340) from a cluster randomized trial of a family-based healthy lifestyle intervention. We assessed the frequency of receiving family support in various forms (encouraging use of cessation resources, praising efforts, checking in, and reminding of familial role). Multiple regression analysis was used to determine associations between family support areas and readiness to consider smoking cessation, controlling for covariates. Results/Findings. Reporting a higher frequency of receiving praise and encouragement for one’s efforts to quit was positively associated with readiness to consider cessation. Other areas of family support were not significant. Conclusions. These findings provide evidence to explore specific areas of family support in enhancing Asian American smokers’ readiness to consider cessation. As there is high interest from Asian American family members to support their smokers for quitting, culturally specific and acceptable strategies are needed to promote smoking cessation among Asian Americans.Publication Incidence of Pediatric Cannabis Exposure Among Children and Teenagers Aged 0 to 19 Years Before and After Medical Marijuana Legalization in Massachusetts(2019-01-01) Whitehill, Jennifer M.; Harrington, Calla; Lang, Cheryl J.; Chary, Michael; Bhutta, Waqaas A.; Burns, Michael D.Importance Pediatric health care contacts due to cannabis exposure increased in Colorado and Washington State after cannabis (marijuana) policies became more liberal, but evidence from other US states is limited. Objective To document the incidence of pediatric cannabis exposure cases reported to the Regional Center for Poison Control and Prevention (RPC) before and after medical marijuana legalization (MML) in Massachusetts. Design, Setting, and Participants Cross-sectional comparison of pediatric cannabis exposure cases 4 years before and after MML in Massachusetts. The exposure cases included those of 218 children and teenagers aged between 0 and 19 years, as reported to the RPC from 2009 to 2016. Census data were used to determine the incidence. Data analysis was performed from November 12, 2018, to July 20, 2019. Exposure Cannabis products. Main Outcomes and Measures Incidence of RPC-reported cannabis exposure cases, both single substance and polysubstance, for the age group of 0 to 19 years, and cannabis product type, coingestants, and clinical effects. Results During the 8-year study period (2009-2016), the RPC received 218 calls involving cannabis exposure (98 single substance, 120 polysubstance) in children and teenagers aged 0 to 19 years, representing 0.15% of all RPC calls in that age group for that period. Of the total exposure cases, males accounted for 132 (60.6%) and females 86 (39.4%). The incidence of single-substance cannabis calls increased from 0.4 per 100 000 population before MML to 1.1 per 100 000 population after (incidence rate ratio, 2.4; 95% CI, 1.5-3.9), a 140% increase. The age group of 15 to 19 years had the highest frequency of RPC-reported cannabis exposures (178 calls [81.7%]). The proportion of all RPC calls due to single-substance cannabis exposure increased overall for all age groups from 29 before MML to 69 afterward. Exposure to edible products increased after MML for most age groups. Conclusions and Relevance Pediatric cannabis exposure cases increased in Massachusetts after medical marijuana was legalized in 2012, despite using childproof packaging and warning labels. This study provides additional evidence suggesting that MML may be associated with an increase in cannabis exposure cases among very young children, and extends prior work showing that teenagers are also experiencing increased cannabis-related health system contacts via the RPC. Additional efforts are needed to keep higher-potency edible products and concentrated extracts from children and teenagers, especially considering the MML and retail cannabis sales in an increasing number of US states.Publication Shifting to Virtual CBPR Protocols in the Time of Corona Virus/COVID-19(2020-01-01) Valdez, Elizabeth Salerno; Gubrium, AlineCOVID-19 has upended community based participatory research (CBPR) projects across the United States and globally. COVID-19 disproportionately impacts historically disenfranchised communities and communities of color, the very communities that CBPR is meant to engage, elevate, and support. In-person activities that help develop rapport and research protocols, build capacity, conduct collaborative data collection and analysis, disseminate findings to the community, and engage in sustainability planning are an impossible practice during the COVID-19 pandemic. The purpose of this article is to describe the challenges and facilitators of shifting to a virtual/online CBPR protocol with a Massachusetts community disproportionately affected by COVID19, as a means to keep them engaged in the research process and to elevate their experiences, perspectives, and voices during this critical time. We include insights about how to facilitate recruitment and compensate community members, form a community advisory board (CAB), hold CAB meetings, and transition participatory qualitative data collection, analysis, and dissemination to a virtual/online framework.Publication Delays in Antiretroviral Therapy Initiation Among HIV-Positive Individuals: Results of the Positive Living with HIV Study(2016-01-01) Poudel, Krishna C.; Buchanan, David R.; Poudel-Tandukar, KalpanaBackground: Lack of early initiation of antiretroviral therapy (ART) remains a major health concern due to increased risk of premature mortality and further HIV transmission. This study explored CD4+ cell count monitoring in relation to delays in ART initiation among HIV-positive individuals in the Kathmandu Valley, Nepal, where ART coverage was only 23.7% in 2011. Design: We recruited a total of 87 ART-naïve, HIV-positive individuals aged 18 to 60 years through the networks of five non-government organizations working with HIV-positive individuals. We collected data on the history of ART initiation, CD4+ cell count monitoring, socio-demographic variables, perceived family support (measured with 10-item Nepali Family Support and Difficulty Scale), depression, and HIV symptom burden. Correlates of ART eligibility were examined using multivariable logistic regression analysis. Results: A total of 72 of the 87 ART-naïve participants (82.8%) had monitored their CD4+ cell count in the past 6 months. Of these, 36 (50%) participants were eligible for ART initiation with CD4+ cell count /mm3. A total of 12 participants had CD4+ cell count /mm3. Lower level of perceived family support was associated with 6.05-fold higher odds (95% confidence interval =1.95 to 18.73) of being ART eligible with a CD4+ cell count /mm3. Conclusions: High rate of delays in ART initiation and the strong association of low perceived family support with ART eligibility in our study participants suggest that HIV service providers should consider the role and impact of family support in influencing individual decisions to initiate ART among eligible HIV-positive individuals.Publication Outreach Strategies to Recruit Low-Income African American Men to Participate in Health Promotion Programs and Research: Lessons From the Men of Color Health Awareness (MOCHA) Project(2018-01-01) Graham, Louis F.; Scott, Lamont; Lopeyok, Erus; Douglas, Henry; Gubrium, Aline; Buchanan, DavidAfrican American men continue to bear a disproportionate share of the burden of disease. Engaging these men in health research and health promotion programs—especially lower-income, African American men who are vulnerable to chronic disease conditions such as obesity and heart disease—has historically proven quite difficult for researchers and public health practitioners. The few effective outreach strategies identified in the literature to date are largely limited to recruiting through hospital clinics, churches, and barbershops. The Men of Color Health Awareness (MOCHA) project is a grassroots, community-driven initiative that has developed a number of innovative outreach strategies. After describing these strategies, we present data on the demographic and health characteristics of the population reached using these methods, which indicate that MOCHA has been highly effective in reaching this population of men.Publication Assessment of HIV testing among young methamphetamine users in Muse, Northern Shan State, Myanmar(2014-01-01) Saw, Yu Mon; Poudel, Krishna C; Ei Kham, Nang Pann; Chan, Nyein; Cope, Jessica E; Wai, Kyi Mar; Tun, Soe; Saw, Thu NandarBackground Methamphetamine (MA) use has a strong correlation with risky sexual behaviors, and thus may be triggering the growing HIV epidemic in Myanmar. Although methamphetamine use is a serious public health concern, only a few studies have examined HIV testing among young drug users. This study aimed to examine how predisposing, enabling and need factors affect HIV testing among young MA users. Methods A cross-sectional study was conducted from January to March 2013 in Muse city in the Northern Shan State of Myanmar. Using a respondent-driven sampling method, 776 MA users aged 18-24 years were recruited. The main outcome of interest was whether participants had ever been tested for HIV. Descriptive statistics and multivariate logistic regression were applied in this study. Results Approximately 14.7% of young MA users had ever been tested for HIV. Significant positive predictors of HIV testing included predisposing factors such as being a female MA user, having had higher education, and currently living with one’s spouse/sexual partner. Significant enabling factors included being employed and having ever visited NGO clinics or met NGO workers. Significant need factors were having ever been diagnosed with an STI and having ever wanted to receive help to stop drug use. Conclusions Predisposing, enabling and need factors were significant contributors affecting uptake of HIV testing among young MA users. Integrating HIV testing into STI treatment programs, alongside general expansion of HIV testing services may be effective in increasing HIV testing uptake among young MA users.Publication Dietary fat quality and serum androgen concentrations in middle-aged men(2023-01-01) Wynne-Ellis, Miika M.; Mursu, Jaakko J.; Tuomainen, Tomi-Pekka; Bertone-Johnson, Elizabeth; Salonen, Jukka T.; Virtanen, Jyrki K.Average testosterone concentrations in men have declined over the last few decades. The reasons for this are not fully known, but changes in dietary fat quality have been suggested to have a role. This study aimed to investigate the associations of different dietary fatty acids with serum androgen concentrations.Publication Timing of hospital admission at first childbirth: A prospective cohort study(2023-01-01) Kjerulff, Kristen H.; Attanasio, Laura B.; Vanderlaan, Jennifer; Sznajder, Kristin K.Background and aims It is difficult for women in labor to determine when best to present for hospital admission, particularly at first childbirth. While it is often recommended that women labor at home until their contractions have become regular and ≤ 5-minutes apart, little research has investigated the utility of this recommendation. This study investigated the relationship between timing of hospital admission, in terms of whether women’s labor contractions had become regular and ≤ 5-minutes apart before admission, and labor progress. Methods This was a cohort study of 1,656 primiparous women aged 18–35 years with singleton pregnancies who began labor spontaneously at home and delivered at 52 hospitals in Pennsylvania, USA. Women who were admitted before their contractions had become regular and ≤ 5-minutes apart (early admits) were compared to those who were admitted after (later admits). Multivariable logistic regression models were used to assess associations between timing of hospital admission and active labor status on admission (cervical dilation 6–10 cm), oxytocin augmentation, epidural analgesia and cesarean birth. Results Nearly two-thirds of the participants (65.3%) were later admits. These women had labored for a longer time period before admission (median, interquartile range [IQR] 5 hours (3–12 hours)) than the early admits (median, (IQR) 2 hours (1–8 hours), p < 0.001); were more likely to be in active labor on admission (adjusted OR [aOR] 3.78, 95% CI 2.47–5.81); and were less likely to experience labor augmentation with oxytocin (aOR 0.44, 95% CI 0.35–0.55); epidural analgesia (aOR 0.52, 95% CI 0.38–0.72); and cesarean birth (aOR 0.66, 95% CI 0.50–0.88). Conclusions Among primiparous women, those who labor at home until their contractions have become regular and ≤ 5-minutes apart are more likely to be in active labor on hospital admission and less likely to experience oxytocin augmentation, epidural analgesia and cesarean birth.Publication Transitions in Health Insurance During the Perinatal Period Among Patients With Continuous Insurance Coverage(2022-01-01) Jeung, Chanup; Attansio, Laura B.; Geissler, Kimberly H.Importance Although health insurance continuity is important during the perinatal period to improve birth outcomes and reduce maternal morbidity and mortality, insurance disruptions are common. However, little is known about insurance transitions among insurance types for individuals who remained insured during the perinatal period. Objective To examine insurance transitions for birthing individuals with continuous insurance, including those with Medicaid and Medicaid managed care coverage, before, during, and after pregnancy. Design, Setting, and Participants This cohort study used January 1, 2014 to December 31, 2018 data from the Massachusetts All-Payer Claims Database. The sample included deliveries from January 1, 2015, to December 31, 2017, to birthing individuals aged 18 to 44 years old with continuous insurance for 12 months before and after delivery. Data were analyzed from November 9, 2021, to September 2, 2022. Exposure Insurance type at delivery. Main Outcomes and Measures The primary outcome was a binary indicator of any transition in insurance type from 12 months before and/or after delivery. The secondary outcomes were measures of any predelivery transition (12 months before delivery month) and any transition during the postpartum period (delivery month to 12 months post partum). Multivariate logit regression models were used to analyze the association of an insurance transition in the perinatal period with insurance type in the delivery month, controlling for age and socioeconomic status based on a 5-digit zip code. Results The analytic sample included 97 335 deliveries (mean [SD] maternal age at delivery, 30.4 [5.5] years). Of these deliveries, 23.4% (22 794) were insured by Medicaid and 28.1% (27 347) by Medicaid managed care in the delivery month. A total of 37.1% of the sample (36 127) had at least 1 insurance transition during the 12 months before and/or after delivery. In regression-adjusted analyses, those individuals covered by Medicaid and Medicaid managed care at delivery were 47.0 (95% CI, 46.3-47.7) percentage points and 50.1 (95% CI, 49.4-50.8) percentage points, respectively, more likely to have an insurance transition than those covered by private insurance. Those covered by Marketplace plans at delivery had a 33.1% (95% CI, 31.4%-34.8%) regression-adjusted predicted probability of having a postpartum insurance transition. Conclusions and Relevance Results of this study showed that insurance transitions during the perinatal period occurred for more than 1 in 3 birthing individuals with continuous insurance and were more common among those with Medicaid or Medicaid managed care at delivery. Further research is needed to examine the role of insurance transitions in health care use and outcomes during the perinatal period.Publication Trends and Characteristics of Manufactured Cannabis Product and Cannabis Plant Product Exposures Reported to US Poison Control Centers, 2017-2019(2021-01-01) Dilley, Julia A.; Graves, Janessa M.; Brooks-Russell, Ashley; Whitehill, Jennifer M.; Liebelt, Erica L.Publication Dental Fluoride Varnish Application During Medical Visits Among Children Who Are Privately Insured(2021-01-01) Geissler, Kimberley H.; Dick, Andrew W.; Goff, Sarah L.; Whaley, Christopher; Kranz, Ashley M.Fluoride varnish is effective at reducing tooth decay, which affects nearly a quarter of US children ages 2 to 5 years and more than half of children ages 6 to 8 years.1,2 To increase young children’s receipt of preventive oral health services, the US Preventive Services Task Force recommends medical providers apply fluoride varnish to young children’s teeth during well-child visits through 5 years of age.2 Offering fluoride varnish in medical settings may increase young children’s receipt of this service because 89% of children younger than 6 years of age had a preventive medical visit in 2019.3 However, fewer than 8% of young Medicaid-enrollees receive fluoride varnish in medical settings,4 and no studies have examined fluoride varnish applications during medical visits for children who are privately insured. Studying children who are privately insured is important because coverage of this service without cost-sharing has been mandated since 2015,5 and fewer than 1 in 3 children under 5 years who are privately insured have an annual dental visit.6 We used data from 4 states to examine fluoride varnish application rates during well-child medical visits and identify characteristics associated with fluoride varnish receipt.Publication Barriers and Facilitators to Implementation of Value-Based Care Models in New Medicaid Accountable Care Organizations in Massachusetts: A Study Protocol(2021-01-01) Goff, Sarah L.; Gurewich, Deborah; Alcusky, Matthew; Kachoria, Aparna G.; Nicholson, Joanne; Himmelstein, JayIntroduction: Massachusetts established 17 new Medicaid accountable care organizations (ACOs) and 24 affiliated Community Partners (CPs) in 2018 as part of a large-scale healthcare reform effort to improve care value. The new ACOs will receive $1.8 billion dollars in state and federal funding over 5 years through the Delivery System Reform Incentive Program (DSRIP). The multi-faceted study described in this protocol aims to address gaps in knowledge about Medicaid ACOs' impact on healthcare value by identifying barriers and facilitators to implementation and sustainment of the DSRIP-funded programs. Methods and analysis: The study's four components are: (1) Document Review to characterize the ACOs and CPs; (2) Semi-structured Key Informant Interviews (KII) with ACO and CP leadership, state-level Medicaid administrators, and patients; (3) Site visits with selected ACOs and CPs; and (4) Surveys of ACO clinical teams and CP staff. The Consolidated Framework for Implementation Research's (CFIR) serves as the study's conceptual framework; its versatile menu of constructs, arranged across five domains (Intervention Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Processes) guides identification of barriers and facilitators across multiple organizational contexts. For example, KII interview guides focus on understanding how Inner and Outer Setting factors may impact implementation. Document Review analysis includes extraction and synthesis of ACO-specific DSRIP-funded programs (i.e., Intervention Characteristics); KIIs and site visit data will be qualitatively analyzed using thematic analytic techniques; surveys will be analyzed using descriptive statistics (e.g., counts, frequencies, means, and standard deviations). Discussion: Understanding barriers and facilitators to implementing and sustaining Medicaid ACOs with varied organizational structures will provide critical context for understanding the overall impact of the Medicaid ACO experiment in Massachusetts. It will also provide important insights for other states considering the ACO model for their Medicaid programs. Ethics and dissemination: IRB determinations were that the overall study did not constitute human subjects research and that each phase of primary data collection should be submitted for IRB review and approval. Study results will be disseminated through traditional channels such as peer reviewed journals, through publicly available reports on the mass.gov website; and directly to key stakeholders in ACO and CP leadership.Publication Navigating the U.S. Health Insurance Landscape for Children with Rare Diseases: a Qualitative Study of Parents' Experiences(2021-01-01) Pasquini, Tai L. S.; Goff, Sarah L.; Whitehill, Jennifer M.Parents of children with rare diseases often face uncertainty about diagnosis, treatment, and costs associated with healthcare for their child. Health insurance status impacts each of these areas, but no U.S. study has explored parents' perceptions of the health insurance impacts on their child's care. This study aimed to qualitatively explore how these parents navigate the complex health insurance system for their children and their experiences in doing so. Methods Semi-structured interviews were conducted with parents of children with metachromatic leukodystrophy (MLD) and spinal muscular atrophy (SMA), chosen for specific disease characteristics and orphan drug status. Participants were recruited via e-mail through patient advocacy organizations between September and December 2018. Interviews were conducted via Skype, were recorded, and professionally transcribed. Modified grounded theory was utilized as a methodology to analyze transcripts in an iterative process to determine themes and sub-themes based on participant described experiences. Results Major themes and subthemes that emerged across the 15 interviews included: (1) difficulties obtaining secondary insurance based on state eligibility criteria; (2) difficulty accessing needed healthcare services; and (3) need for repeated interactions with insurance representatives. The absence of clearly documented or widely recognized clinical guidelines exacerbated the difficulty accessing care identified as necessary by their healthcare team, such as therapy and equipment. An explanatory model for parent's experiences was developed from the themes and subthemes. The model includes the cyclical nature of interacting with insurance for redundant reauthorizations and the outside support and financial assistance that is often necessary to address their child's healthcare needs. Conclusions With complex health conditions, small setbacks can become costly and disruptive to the health of the child and the life of the family. This study suggests that patients with rare diseases may benefit from time limits for processing coverage decisions, increasing transparency in the claims and preauthorization processes, and more expansive authorizations for on-going needs. Additional studies are needed to understand the full scope of barriers and to inform policies that can facilitate better access for families living with rare diseases.Publication Community Perspectives on the Creation of a Hospital-Based Doula Program(2021-01-01) Attanasio, Laura B; DeCosta, Marisa; Kleppel, Reva; Govantes, Tiki; Sankey, Heather Z; Goff, Sarah LObjective: Racial and ethnic inequities in perinatal health outcomes are pervasive. Doula support is an evidence-based practice for improving maternal outcomes. However, women in lower-income populations often do not have access to doulas. This study explored community perspectives on doula care to inform the development of a hospital-based doula program to serve primarily low-income women of color. Methods: Four focus groups and four individual interviews were conducted with: (1) women who were pregnant or parenting a child under age 2 (n=20); (2) people who had provided support during a birth in the previous 2 years (n=5); and (3) women who had received doula training (n=4). Results: Participants had generally positive perceptions of doula services. Many aspects of doula support desired by participants are core to birth doula services. Participants identified ways that doulas could potentially address critical gaps in health care services known to impact outcomes (e.g., continuity of care and advocacy), and provide much-needed support in the postpartum period. Responses also suggested that doula training and hospital-based doula programs may need to be adapted to address population-specific needs (e.g., women with substance use disorder and younger mothers). Novel program suggestions included “on call” informational doulas. Conclusions: Findings suggested that women in racial/ethnic minority and lower income groups may be likely to utilize a hospital-based doula program and identified adaptations to traditional doula care that may be required to best meet the needs of women in groups with higher risk of poor maternal health and birth outcomes.Publication Associations between the Patient-Centered Medical Home and Preventive Care and Healthcare Quality for Non-Elderly Adults with Mental Illness: A Surveillance Study Analysis(2016-01-01) Bowdoin, Jennifer J.; Rodriguez-Monguio, Rosa; Puleo, Elaine; Keller, David; Roche, JoanBackground Patient-centered medical homes (PCMHs) may improve outcomes for non-elderly adults with mental illness, but the extent to which PCMHs are associated with preventive care and healthcare quality for this population is largely unknown. Our study addresses this gap by assessing the associations between receipt of care consistent with the PCMH and preventive care and healthcare quality for non-elderly adults with mental illness. Methods This surveillance study used self-reported data for 6,908 non-elderly adults with mental illness participating in the 2007–2012 Medical Expenditure Panel Survey. Preventive care and healthcare quality measures included: participant rating of all healthcare; cervical, breast, and colorectal cancer screening; current smoking; smoking cessation advice; flu shot; foot exam and eye exam for people with diabetes; and follow-up after emergency room visit for mental illness. Multiple logistic regression models were developed to compare the odds of meeting preventive care and healthcare quality measures for participants without a usual source of care, participants with a non-PCMH usual source of care, and participants who received care consistent with the PCMH. Results Compared to participants without a usual source of care, those with a non-PCMH usual source of care had better odds of meeting almost all measures examined, while those who received care consistent with the PCMH had better odds of meeting most measures. Participants who received care consistent with the PCMH had better odds of meeting only one measure compared to participants with a non-PCMH usual source of care. Conclusions Compared with having a non-PCMH usual source of care, receipt of care consistent with the PCMH does not appear to be associated with most preventive care or healthcare quality measures. These findings raise concerns about the potential value of the PCMH for non-elderly adults with mental illness and suggest that alternative models of primary care are needed to improve outcomes and address disparities for this population.