PurposeTo examine the association between sociodemographic determinants and parent-reported up-to-date childhood vaccination status in Tennessee.DesignCross-sectional statewide survey.SettingAll 95 Tennessee counties, July 2022 to May 2024. Surveys were distributed at community outreach events (health fairs, Head Start programs, community baby showers), and community organizations (schools, daycares, and preschools).SampleParents or caregivers of children aged 18 years and younger (N = 8954).MeasuresThe primary outcome was parent-reported up-to-date childhood vaccination status. Covariates included child's age, health insurance status, parental race/ethnicity and education, household income, and rural/urban residency.AnalysisDescriptive statistics and log-binomial regression models were used to assess associations between sociodemographic factors and vaccination status. Stratified analyses were conducted by rural and urban status. Adjusted prevalence (aP) and 95% confidence intervals (CIs) with robust estimates were reported.ResultsOverall, 96.5% reported that their children were up-to-date on vaccinations. The lowest vaccination rates were observed among children of multiracial (86.4%), and Asian/Native Hawaiian/Pacific Islander (90.3%) parents. Children without health insurance had a significantly higher prevalence of under-vaccination (aP = 0.104; 95% CI, 0.079-0.137) compared to insured children (aP = 0.029; 95% CI, 0.025-0.033). Across both rural and urban areas, under-vaccination was significantly associated with insurance, race, and child age, while parental education was significant only in urban areas and household income only in rural areas.ConclusionsFindings highlight critical gaps in vaccine coverage tied to insurance, race, and age. Targeted outreach to underserved and low-education communities is needed to promote equity in childhood vaccination.

Objective: Male allies play an important role in sexual assault prevention, yet many college sexual assault prevention programs struggle to recruit and retain men. This study aims to identify barriers to recruitment and retention of male sexual assault prevention peer educators. Participants: Seventeen undergraduate male student leaders participated in this study during summer 2018. Methods: Semi-structured phone interviews were conducted, recorded, and transcribed. Response data were thematically analyzed. Results: Barriers to recruitment include perceived gender norms and discomfort with the topic of sexual assault. Barriers to retention include male peer educators' perception that women are resistant to men discussing sexual assault. Suggestions for improving recruitment and retention efforts are also identified. Conclusions: Recruitment and retention of male sexual assault prevention peer educators may require recruitment approaches that are tailored to men and programmatic changes that position men as allies in sexual assault prevention.

BACKGROUND:Rest breaks have been shown to reduce acute fatigue, yet not all nurses who take rest breaks report lower fatigue. Psychological detachment-letting go of work-related thoughts-during rest breaks and workload may be key factors in explaining this phenomenon.OBJECTIVE:To examine the mediating role of psychological detachment during rest breaks and determine how workload moderated that pathway to lower acute fatigue among hospital nurses.METHODS:In this cross-sectional study, data were collected from 1861 12-hour shift nurses who answered an online survey between July and September 2021. The survey included measures of occupational fatigue, psychological detachment from work, workload, and questions on breaks, work, health, and demographics. Structural equation modeling was used in Mplus 8.9 software to estimate the direct and indirect effects of rest breaks on acute fatigue at 3 levels of workload.RESULTS:Nurses, on average, reported high acute fatigue, rarely experienced psychological detachment during rest breaks, and reported heavy workloads. Around 60% were able to sit down for a break on their last shift but with patient-care responsibilities. The relationship between taking a rest break and acute fatigue was fully mediated by psychological detachment from work. However, this relationship only held in the context of manageable workloads.CONCLUSION:Our findings showed that within-shift recovery is possible when nurses can psychologically detach from work during rest breaks. However, this within-shift recovery mechanism was disrupted for nurses with heavy workloads.

AbstractAimThis study aimed to explore whether 30‐min rest breaks were as effective at lowering acute fatigue among 12‐h shift hospital nursing staff who cared for patients with COVID‐19 as among those who did not.DesignThe study was cross‐sectional in design.MethodsData from the SAFE‐CARE study collected online between May and June 2020 were used. A subsample (N = 338) comprised of nursing staff who reported working 12‐h shifts, and providing direct patient care in hospitals was used in this study. Data on socio‐demographics, work and rest breaks, and subjective measures of fatigue, psychological distress, sleep and health were used. Hierarchical multiple linear regression followed by stratified analyses was conducted to explore the relationships between rest breaks and acute fatigue among nursing staff groups with and without COVID‐19 patient care.ResultsThe sample, on average, had high acute fatigue. Around 72% reported providing care to patients with COVID‐19, and 71% reported taking rest breaks ‘sometimes’, ‘often’ or ‘always’. In the group that cared for patients with COVID‐19, there was no significant relationship between rest breaks and acute fatigue (p = .507). In the group that cared for patients hospitalized for other reasons, rest breaks were associated with lower acute fatigue (p = .010).ConclusionOur findings showed both the importance and inadequacy of rest breaks in reducing acute fatigue. The process of within‐work recovery is complex, and routine rest breaks should be facilitated by nursing management on hospital units during and after the COVID‐19 pandemic.ImpactRest breaks may present an effective strategy in lowering fatigue. Although rest breaks were not associated with less fatigue among staff caring for patients with COVID‐19, other co‐workers experienced some fatigue recovery. For frontline nursing staff, routine rest breaks are encouraged, and a systematic evaluation pertaining the sufficiency of rest breaks during high work demands in future research is needed.

This two-part study explored whether discrimination encoded into U.S. school absenteeism policies leads to racially minoritized students being overrepresented in the juvenile court system. First, we examined unexcused absenteeism policies in a nationally representative school district sample (n = 97). All districts excused absences for reasons White students often miss school but not necessarily for reasons racially minoritized students do. Next, in three school districts we documented large racial disparities in both the proportion of absences designated unexcused (Whites 13%, Asians 18%, Hispanics 21%, Blacks 24%, and American Indians 24%) and risk of court petition for truancy, even after accounting for the total number of absences: Whites hazard ratio (HR) = 1.0; Asians HR = 1.15, 95% confidence interval (CI) [0.98, 1.36]; Hispanics HR = 1.60, 95% CI [1.34, 1.92]; Blacks HR = 2.17, 95% CI [1.88, 2.50]; and American Indians HR = 3.94, 95% CI [3.12, 4.97]. Disproportionality in unexcused absenteeism fully explained the Hispanic/White and partially explained the Black/White and American Indian/White court petition disparities.

We examined the effect on attendance of a truancy court-diversion program for elementary students. Truancy court-diversion programs represent a shift from a law-and-order approach toward a public health model to address school absenteeism. Instead of directly referring parents of truant elementary students to child protection services or juvenile court, most court-diversion programs educate parents about the importance of school attendance and create an attendance contract that includes social service referrals. Despite being widely implemented, truancy court-diversion models have not been rigorously evaluated. Using 10 years of administrative data from multiple state and local agencies from Minnesota, we constructed a counterfactual of students from schools that did not implement truancy court-diversion. We used difference-in-differences methods to test whether parent education and attendance contracts improved attendance relative to direct referral to child protection services or court. We failed to reject the null hypothesis of no program effect. Most truancy program evaluations use a pre- and post-mean comparison, but our analysis suggested that the magnitude of the bias in such studies is substantial because absenteeism showed a pattern of regression to the mean.

McNeely, Clea A. DrPH, MA; Hutson, Sadie P. PhD, RN, WHNP-BC; Sturdivant, Tara L. MD; Jabson, Jennifer M. PhD, MPH; Isabell, Brittany S. MPH Author Information

Over 60% of US school districts implement court diversion programs to address chronic unexcused absenteeism, yet the effectiveness of these programs is not known. We evaluated whether the Truancy Intervention Program (TIP) improved the school attendance of students in grades 7–10 in a metropolitan county in the Midwestern USA. Similar to most truancy court diversion programs, TIP consisted of three increasingly intrusive steps: (1) a parent meeting, (2) a hearing to develop an attendance contract, and (3) a petition to juvenile court. The intervention group consisted of students from the intervention county who had been referred to TIP between 2006 and 2009. The comparison group was drawn from a contiguous, same-sized, and socio-demographically similar county that petitioned truant students directly to court. To construct the comparison group, we applied multi-level matching procedures to linked, individual-level administrative data from eight state and local agencies for all public school students in the state between 2004 and 2015. Using the matched samples, we conducted difference-in-differences analyses to identify program effects for two intervention groups: all students referred to TIP and students whose family participated in the group parent meeting. In the 4 years after the intervention, the intervention groups had similar or slightly lower attendance than the comparison groups. However, most coefficients were not statistically significant, and there was no consistent pattern of effects across different samples and different specifications of the intervention. This pattern of findings was not robust enough to conclude that the program influenced school attendance.

BACKGROUND Foreign-born children rarely use traditional school mental health services. Comprehensive programs that combine mental health services with academic, economic, and socioemotional supports reach more foreign-born children and improve wellbeing. However, little practical guidance exists regarding how to best combine these diverse services. METHODS To identify essential service components and their organization, we interviewed 92 parents, school staff, mental health providers, and community agency staff from 5 school-linked mental health programs designed specifically to serve immigrant and refugee youth. RESULTS Foreign-born parents did not distinguish between academic, behavioral, and emotional help for their children; these western categorizations of functioning were not meaningful to them. Consequently, programs needed to combine 4 components, organized in a pyramid: family engagement, assistance with basic needs, assistance with adaptation to a new culture, and emotional and behavioral supports. Family engagement was the foundation upon which all other services depended. Assistance with economic and cultural stressors directly promoted emotional wellbeing and helped parents trust clinical mental health interventions. CONCLUSIONS Specific strategies to implement the 4 essential components include home visits by program staff, a one-stop parent center located in the school to help with basic needs, working with cultural brokers, and informed consent procedures that clearly explain recommended care without requiring immigrant and refugee parents to internalize western conceptualizations of psychopathology. Future evaluations should assess the cost and effectiveness of these strategies. These data are essential to advocate payment for these nonclinical services by traditional funding mechanisms.

AffiliationsClea A. McNeely is with the Department of Public Health, University of Tennessee, Knoxville.

Background: The lifetime prevalence of unintentional pregnancy among women enrolled in medically assisted treatment (MAT) for opioid use disorder (OUD) has been reported to exceed 80%. Consistent voluntary contraception use by women enrolled in MAT programs can reduce their risk of unintended pregnancies and increase their opportunity to plan the family size they want, yet little is understood about past and current contraception use or associated barriers and facilitators for this population of women. Materials and Methods: Women enrolled in treatment for OUD at two MAT clinics in East Tennessee were invited to participate in an anonymous survey about contraception. We describe the sociodemographic and health characteristics of the women (N=287; estimated response rate of 81.0%), report on their contraception knowledge and attitudes, and assess how these characteristics are associated with current contraception use. Results: Most of the 287 women had been sexually active in the past 12 months (88%), were pregnant at least once (98%), and were insured (58%). Women having undergone bilateral tubal ligation had a greater average number of pregnancies (including those while on birth control), lower mean levels of depressed mood, and higher mean level of agreement that avoiding pregnancy now was important and that pregnant women should not use painkillers, compared to the women not using contraception. Conclusions: Strategies to ensure all women enrolled in MAT for OUD have knowledge of effective contraception and affordable, quality contraception care that is responsive to their complicated and oftentimes traumatic histories are necessary to enhance the women's reproductive health.

CONTEXT:Law enforcement has been the primary strategy for addressing the opioid epidemic. As a result, the incarceration rate for women in county jails has increased more than 800% since 1980, and most women inmates struggle with substance use disorders. There is a large unmet need for contraception among women in county jails.PROGRAM:The East Region of the Tennessee Department of Health partnered with county correctional facilities to provide comprehensive family planning education and voluntary long-acting reversible contraception (LARC) to women in 15 jails.IMPLEMENTATION:Incarcerated women were invited to attend a comprehensive family planning education session conducted in the jail by health department nurses. The sessions included information on neonatal abstinence syndrome. The nurses explained that the women could receive intrauterine devices, implants, and injectable progesterone while incarcerated and come to the health department for all contraceptive methods upon release. Between January 2014 and June 2017, nurses conducted 182 education sessions, and 794 women received a LARC. Method placement occurred in the jails or at the local health department. No adverse effects were known to have occurred.EVALUATION:We collected pilot data to explore the accuracy and the comprehensiveness of the family planning education session and whether the incarcerated women experienced the program as voluntary. All 18 women inmates interviewed reported experiencing the program as voluntary. Using published and administrative data, we roughly estimated that the program prevented between 270 and 460 unintended pregnancies and between 40 and 52 cases of neonatal abstinence syndrome in the first year after the women received a method. This represents a cost savings to Medicaid of $1.4 million.DISCUSSION:The partnership demonstrated the feasibility of providing voluntary comprehensive family planning education and access to highly effective contraception for women inmates who, as a group, face a host of political, socioeconomic, and personal barriers to reproductive health care.

BackgroundMost studies of political conflict rely on imported measures of mental health. We identified and tested a local definition of suffering in the occupied Palestinian territory that we labelled "Feeling Broken or Destroyed".MethodsThe construct was identified in group interviews completed in Arabic in 2010, with 68 residents as the total sample size from the West Bank, East Jerusalem, and the Gaza Strip aged 30–40 years. Survey items were then written and given to a representative sample of people (same age group in the same territories) in June 2011 (n=508; study 1), and November 2011 (n=1778; study 2). All data were collected with written consent by the Palestinian Center for Policy and Survey Research, who purposively selected participants to represent key elements of diversity in Palestinian society.FindingsParticipants referred in Arabic to a type of suffering not included in standard instruments, which the participants typically associated with economic and political hardships. Descriptions from the participants included being or feeling: broken, crushed (muḥaṭṭima), destroyed, (mudammira), exhausted, and tired (ta'bāna). Aspects of the participants were described as the self or spirit (an-nafs), morale (al-ma'naūiyyat), and hopes or ambition for the future (amālak aū ṭamūḥatak ban-nisba lil-mustaqbil). The following survey items were then written in English, translated to Arabic, and back-translated. The survey was administered in Arabic, asking the respondents to rate how often during the past 2 weeks they "felt that your spirit or morale is broken or destroyed?" (Kam murra aḥsast ba'n nasfiyyatak wa ma'naūiyyatak muḥaṭṭima?); "felt that your ambitions and hopes for the future are destroyed?" (Kam murra aḥsast ba'n amālak aū ṭamūḥatak ban-nisba lil-mustaqbil muḥaṭṭima?); and "felt emotionally or psychologically exhausted?" (Kam murra aḥsast ba'nak murhaq 'āṭafiyyan aū nafsiyyan?). Internal consistency of these items across subgroups in studies 1 and 2 ranged from 0·80 to 0·87. Discriminant validity was evident in that these items factored separately from standard mental health items in principal components analysis. The scale correlated moderately in both data sets with: feelings of depression (study 1: r=0·46; p<0·0001; study 2: r=0·55; p<0·0001) and trauma-related stress (study 1: r=0·21; p<0·001; study 2: r=0·21; p<0·001).InterpretationContextualised suffering can be discerned through careful interviewing, and can be efficiently and reliably measured, tested, and quantitatively distinguished from traditional mental health measures.FundingThe Jacobs Foundation, Switzerland.

Objectives. To estimate the long-term association between Israeli-imposed restrictions on travel for medical care in the occupied Palestinian territory and health status in adulthood. Methods. Using event history calendar methods, we collected annual data from 1987 to 2011 from a representative sample of 1778 Palestinians aged 32 to 43 years and analyzed the subsample of whomever had a serious medical condition and needed to travel for medical care (n = 246; contributing 1163 person-years). We used ordered logistic regression with person-year data to test the association between movement restrictions from 1987 to 2011 and health status in 2011. Results. Two thirds (65%; n = 161) of participants reported travel restrictions, and 38% (n = 92) reported ever being barred from travel for medical care. Compared with study participants who experienced no travel restrictions in a year (n = 559 person-years), those who were barred from travel in that same year (n = 122 person-years) reported worse self-rated health (57% vs 22% reported bad or very bad self-rated health; P < .05) and greater limits on daily functioning caused by physical health (41% vs 16% reported regular limits; P < .05). Conclusions. Being barred from travel for medical care was associated with poor health as long as 25 years later.

Self-rated health (SRH) is measured with a single question asking respondents to rate their general health. SRH is easy to measure, has measurement equivalence across racial/ethnic groups among adolescents, and in population surveys consistently predicts physical and mental health, health care utilization, and mortality. Not surprisingly, there is growing interest in the clinical utility of SRH to identify individual adolescents’ risk of chronic illness and health care utilization. Although SRH consistently predicts health status in epidemiologic studies of populations, it may not reliably and validly predict risk for individuals in clinical settings. Studies of the clinical utility of SRH suffer from major methodological limitations. First, existing studies control for too few predictors. The appropriate question is whether measuring SRH provides additional information over and above clinical variables already collected by providers. Second, few studies use appropriate statistical methods. Models to longitudinally predict individual outcomes should be evaluated on their ability to 1) correctly predict the proportion that will experience the outcome (calibration), 2) correctly identify which individuals in the dataset will experience the outcomes (discrimination), and 3) assess improvements in discrimination with the addition of a single indicator (reclassification). In this paper we apply long-standing and newly developed methods to determine if clinical assessment of SRH can increase healthcare providers’ ability to identify which adolescents will be heavy health care utilizers or have a chronic disease in five years.

BackgroundLong-term effects of political imprisonment on functioning are unknown. This retrospective study explored the association between economic, political, psychological, physical, community, and family functioning and political imprisonment during a span of 25 years in a population-based sample of Palestinian men aged 32–43 years in the West Bank, East Jerusalem, and the Gaza Strip.MethodsEvent-history calendars and surveys of present level of functioning were given by the Palestinian Center for Policy and Survey Research to a representative sample of 884 men who completed it. Informed consent was obtained from all participants. Latent class models were used to identify patterns of imprisonment across 25 years (1987–2011). We compared mean scores of 13 measures of functioning across five latent classes of political imprisonment representing the main trajectories of imprisonment during the 25 years. To assess these 13 measures, we used previously established and validated scales for four measures, whereas others we assessed with scales we had developed and validated ourselves.FindingsThe overall response rate was 97%. Of the 884 men who completed the study, 26% (233 men) had been politically imprisoned at some point. Men imprisoned mainly during the first Intifada (1987–93; 87 men) or the Oslo period (1994–99; 78 men) did not significantly differ from men who had never been imprisoned (651 men) with respect to 12 indicators of functioning. Men who had been politically imprisoned reported higher trauma-related stress: during first Intifada mean stress was scored 1·32 (95% CI 1·05–1·58), and Oslo mean of 1·54 (95% CI 1·29–1·80), compared with men not imprisoned mean of 1·04 (95% CI 0·96–1·13; range score of 0–3; p=0·030 and p<0·001, respectively). Men imprisoned during 2006–11 (21 men), reported lower functioning than never-imprisoned men on six measures: work insecurity (mean 2·06 [95% CI 1·70–2·42] vs 2·52 [95% CI 2·40–2·65], p=0·017, range 1–5), ability to pay for their children's education (mean 2·88 [95% CI 2·31–3·44] vs 3·47 [95% CI 3·35–3·59], p=0·05, range 1–5), community belonging (mean 3·08 [95% CI 2·77–3·38] vs 3·42 [95% CI 3·34–3·51], p=0·036, range 1–5), feelings of depression (mean 1·25 [95% CI 1·03–1·47] vs 0·96 [95% CI 0·90–1·03], p=0·015, range 0–3), feeling broken or destroyed (a locally defined measure of suffering suggesting that their morale is damaged; mean 3·71 [95% CI 3·27–4·14] vs 2·99 [95% CI 2·60–3·38], p=0·035, range 1–5), and functional limitations (mean 2·84 [95% CI 2·39–3·30] vs 2·28 [95% CI 2·19–2·38], p=0·015, range 1–5).InterpretationFindings suggest long-term resilience of these men after political imprisonment. Efforts to support previous political prisoners in the occupied Palestinian territory should provide support to those recently released from political imprisonment to promote long-term recovery.FundingThe Jacobs Foundation, Switzerland.

In the United States, there is concern that recent state laws restricting undocumented immigrants' rights could threaten access to Medicaid and the Children's Health Insurance Program (CHIP) for citizen children of immigrant parents. Of particular concern are omnibus immigration laws, state laws that include multiple provisions increasing immigration enforcement and restricting rights for undocumented immigrants. These laws could limit Medicaid/CHIP access for citizen children in immigrant families by creating misinformation about their eligibility and fostering fear and mistrust of government among immigrant parents. This study uses nationally-representative data from the National Health Interview Survey (2005-2014; n = 70,187) and comparative interrupted time series methods to assess whether passage of state omnibus immigration laws reduced access to Medicaid/CHIP for US citizen Latino children. We found that law passage did not reduce enrollment for children with noncitizen parents and actually resulted in temporary increases in coverage among Latino children with at least one citizen parent. These findings are surprising in light of prior research. We offer potential explanations for this finding and conclude with a call for future research to be expanded in three ways: 1) examine whether policy effects vary for children of undocumented parents, compared to children whose noncitizen parents are legally present; 2) examine the joint effects of immigration-related policies at different levels, from the city or county to the state to the federal; and 3) draw on the large social movements and political mobilization literature that describes when and how Latinos and immigrants push back against restrictive immigration laws. (C) 2017 Elsevier Ltd. All rights reserved.

BACKGROUND:The US education system must find creative and effective ways to foster the healthy development of the approximately 2 million newly arrived immigrant and refugee adolescents, many of whom contend with language barriers, limited prior education, trauma, and discrimination. We identify research priorities for promoting the school success of these youth.METHODS:The study used the 4-phase priority-setting method of the Child Health and Nutrition Research Initiative. In the final stage, 132 researchers, service providers, educators, and policymakers based in the United States were asked to rate the importance of 36 research options.RESULTS:The highest priority research options (range 1 to 5) were: evaluating newcomer programs (mean = 4.44, SD = 0.55), identifying how family and community stressors affect newly arrived immigrant and refugee adolescents' functioning in school (mean = 4.40, SD = 0.56), identifying teachers' major stressors in working with this population (mean = 4.36, SD = 0.72), and identifying how to engage immigrant and refugee families in their children's education (mean = 4.35, SD = 0.62).CONCLUSION:These research priorities emphasize the generation of practical knowledge that could translate to immediate, tangible benefits for schools. Funders, schools, and researchers can use these research priorities to guide research for the highest benefit of schools and the newly arrived immigrant and refugee adolescents they serve.