PurposeThe South Carolina Choose Well contraceptive access initiative launched a statewide media campaign, No Drama, in 2018. We evaluated the reach and effectiveness of No Drama and provided recommendations for future campaigns.DesignA convergent mixed methods design triangulated data collected between 2018 and 2021 from (1) surveys of women of reproductive age seeking care at Choose Well-participating clinics in South Carolina (n = 908); (2) interviews with clinic staff (n = 100); and (3) metrics about statewide utilization of the campaign.SettingCommunity - No Drama was implemented in communities across South Carolina. Clinical - Research data were collected at family planning (health department and federally qualified health center) clinics.MeasuresExposure to and reported effectiveness of the campaign in encouraging contraceptive appointments and contraceptive use were examined. Clinic staff perceptions of campaign strengths and areas for improvement were also explored.AnalysisModified Poisson regression models with Generalized Estimating Equations, and inductive coding with content analysis, were used to analyze survey and interview data, respectively. Contraceptive appointments requested through No Drama were examined.ResultsNo Drama produced nearly 22 000 contraceptive appointment requests between 2018 and 2021. One-third of reproductive-age patients at Choose Well-participating clinics reported exposure to the campaign. Exposure differed by race/ethnicity and educational attainment of patients. Nearly half (46%) of exposed patients found the campaign very effective at encouraging contraceptive appointments. Perceiving the campaign as very effective in encouraging contraceptive counseling appointments and encouraging contraceptive use was associated with the frequency of exposure. Clinic staff reported that the campaign had widespread visibility and connected patients to clinics.ConclusionNo Drama reached a portion of its intended audience and facilitated access to contraceptive care among exposed people. Future campaigns may consider increasing the rate of advertisements, ensuring clear messaging, involving community partners in campaign design, and diversifying campaign materials and locations.

Background Smoking during pregnancy remains a public health concern in the United States, with disproportionately higher rates observed in rural populations. These differences are influenced by factors at system and community levels. This study examines the association between smoking during pregnancy, social risk factors, and geographic context in North Carolina, a state in the Southeast United States. Methods An ecological cross-sectional study was conducted at the county-level using publicly available secondary data from 2018–2022, incorporating spatial statistical methods to examine geographic variation and area-level drivers of smoking during pregnancy. Key independent variables included rural-urban status (2023 Rural-Urban Continuum Codes), managed care regions (North Carolina Department of Health and Human Services designations), and county-level indicators of socioeconomic instability (e.g., median household income), healthcare access (e.g., insurance coverage, OB-GYN physician rate), and neighborhood/built environment (e.g., broadband access, food availability). Descriptive analyses, Spearman correlations, and ordinary least squares (OLS) regression were conducted. Spatial dependence was evaluated using Global Moran’s I and Lagrange Multiplier tests, with a spatial lag regression model applied to adjust for spatial autocorrelation. Results The average county-level rate of smoking during pregnancy was 10.3%, ranging from 1.6% to 21.6%. Significant spatial clustering was observed (Global Moran’s I = 0.55, p < 0.01), with high-high clusters in western counties (Regions 1 and 2) and low-low clusters in central counties (Region 4). Rural counties had significantly higher smoking rates (11.98%) than urban counties (8.19%; p < 0.0001) and significantly greater socio-economic disadvantage. In the OLS model (R² = 0.58), rurality, lower median household income, fewer OB-GYNs, and regional location were significantly associated with higher smoking rates. Spatial lag modeling improved model fit (R² = 0.71) and confirmed spatial dependence (ρ = 0.53, p < 0.001). Rurality, OB-GYN rates, and regional location remained significant predictors. Conclusions Smoking during pregnancy demonstrates distinct geographic clustering in North Carolina, in the Southeast United States. Rates are influenced by rurality, healthcare access, and regional context. Spatial models are crucial for informing place-based prevention efforts. Leveraging tobacco taxes, Master Settlement Agreement funds, and investments in rural economic development promise to reduce tobacco-related maternal and child health disparities.

BACKGROUND:Biological and behavioral factors influence interpregnancy intervals. Individualized family planning goals and preferences regarding contraception must be supported through shared decision-making approaches. Contraceptive counseling throughout the perinatal period is multifaceted whereby intersecting health-related choices including breastfeeding are co-occurring. This study explores multi-level factors influencing postpartum contraceptive decision-making among women and perinatal care providers in a rural region of the Southeast United States. METHODS:The qualitative study triangulated perspectives of postpartum mothers (n=16) and perinatal care providers (n=8). Perinatal care providers included a range of professionals including midwives, lactation consultants, and doulas. Interviews were conducted via phone, audio recorded, and transcribed. An inductive content analysis was applied to coding and analysis. RESULTS:Participants from both groups discussed the importance of knowledge about contraceptive method options, including safe methods for while breastfeeding. Although, perceptions about the impact of contraception on milk supply varied among both mothers and providers. Mothers and providers elevated the importance of provider support for individualized decisions given personal preferences and family planning goals. Multiple points of access to contraception were noted, including in-hospital provision, which can facilitate access. Providers emphasized the influence of complex social risk factors such as limited financial resources and challenges with access to housing, food, and transportation. CONCLUSIONS:Postpartum contraceptive decision-making is an ongoing process based on individualized preferences. Mothers can be supported, in part, through providers acknowledging social, economic, and historical forces impacting decision-making. Future research to investigate the role of interdisciplinary care teams to enhance perinatal healthcare service provision is warranted.

OBJECTIVES:Short interpregnancy intervals are associated with preterm births. Increasing access to postpartum contraception is a preventive intervention. Best practice recommendations suggest that postpartum individuals exclusively breastfeed for up to 6 months. Conversations about these two topics tend to occur simultaneously throughout the perinatal period. This study explores the intersection between infant feeding and postpartum contraception. METHODS:Semistructured key informant interviews were conducted with postpartum individuals and providers from throughout western North Carolina. Interviews were audio recorded and transcribed. The "Sort and Sift, Think and Shift" method was applied. Emergent themes were identified by systematically generating summaries, memoranda, and quotation diagrams independently by two coders. RESULTS:Key themes included the need to prioritize individual decision-making autonomy and to provide prenatal patient education about infant feeding and postpartum contraception. Participants also discussed the types of social support needed for successful breastfeeding efforts and the impact of infant feeding on mental health. Contextual factors related to infant feeding and postpartum contraceptive decision-making encompassed cultural influences (eg, the historical context of reproductive rights and breastfeeding in public), the inherent challenges of rurality (eg, lack of transportation and the closure of labor and delivery units), and family leave and workplace policies. CONCLUSIONS:Infant feeding method and postpartum contraception are highly individualized decisions, which are supported through patient education and shared decision making, particularly during the prenatal period. Findings suggest the importance of incorporating infant feeding within the sexual and reproductive health literature.

PURPOSE:Area-level vulnerability and resilience indices combine multiple dimensions of demographic, economic, and environmental factors into a single measure of area-level risk. These indices are widely used to allocate resources in health care and public health. We investigated how commonly used, existing area-level indices correlate with each other, and how they differ by geography, comparing rural and urban areas. METHODS:Seven publicly available indices were selected for inclusion. Rurality was defined by Rural-Urban Continuum Codes and/or Rural-Urban Commuting Areas, depending on the geographic level of each index. Percentiles were obtained or calculated for each index and compared by rurality. FINDINGS:We find that these area-level indices are not substitutes for each other, and they differ significantly across the rural-urban continuum in conflicting ways. Three different patterns generally emerged from analysis: indices that increase as geography becomes more rural; indices that decrease as geography becomes more rural; and indices with the greatest values among middle levels of geography. CONCLUSIONS:Findings from this work underscore the importance of better understanding how area-level indices may differ across the United States and by specific populations. When using area-level indices in policy and resource allocation, strategic selection and implementation considering differences by rurality may be warranted.

Background and Objectives:To fully understand the impact of unintended pregnancy, as well as to evaluate the implementation and outcomes of programs targeted at reducing unintended pregnancy, it is critical that researchers be able to collect comprehensive data from health clinics that provide these services in vulnerable communities.Methods:Our paper details recruitment and incentive strategies, as well as the theories that guided them, which allowed us to achieve a high survey response rate among health clinic administrators in public health clinics in 2 Southeastern states-South Carolina and Alabama-both of which have high rates of unintended pregnancy.Results:Grounded in organizational theory, and utilizing the Tailored Design Method, we achieved a 68% response rate utilizing paper and web survey administration with multiple contact modes. Our incentive structure comprised both traditional cash-based and food-based incentives.Conclusions:Findings indicate high response rates are achievable despite high survey burden (ie, detailed information, length of survey). We found that sample screening was critical and that food-based incentives made an impression on respondents that positively impacted the researcher-respondent relationship. Providing detailed methodology and additional literature will assist researchers working with similar populations-a gap in the applied methodological literature that was problematic at the project's onset.

OBJECTIVES:Block grant funding provides federal financial support to states, with increased flexibility as to how those funds can be allocated at the community level. At the state level, block grant amounts and distributions are often based on outdated formulas that consider population measures and funding environments at the time of their creation. We describe variation in state-level funding allocations for 5 federal block grant programs and the extent to which funding aligns with the current needs of state populations. METHODS:We conducted an analysis in 2022 of state block grant allocations as a function of state-level characteristics for 2015-2019 for all 50 states. We provide descriptive statistics of state block grant allocations and multivariate regression models for each program. Models include base characteristics relevant across programs plus supplemental characteristics based on program-specific goals and state population needs. RESULTS:Mean state block grant allocations per 1000 population by program ranged from $618 to $21 528 during 2015-2019. Characteristics associated with state allocations varied across block grants. For example, for every 1-percentage-point increase in the percentage of the population living in nonmetropolitan areas, Preventive Health and Health Services Block Grant funding was approximately $7 per 1000 population higher and Community Services Block Grant funding was approximately $40 per 1000 population higher. Few supplemental characteristics were associated with allocations. CONCLUSIONS:Current block grant funding does not align with state characteristics and needs. Future research should consider how funds are used at the state level or allocated to local agencies or organizations and compare state block grant allocations with other types of funding mechanisms, such as categorical funding.

The public health workforce continues to atrophy due to mass and early retirement, under-funding, slow hiring processes, lack of advancement opportunities, and shifting policies. Organizational research into workforce sustainability is crucial for ensuring a robust, diverse staff capable of delivering essential public health services. We examined career ladders, a potential solution to workforce challenges, through interviews with 10 health departments (HDs) across seven states. Interview participants were recruited from HDs using or planning career ladders held administrative positions, and had a role in the hiring process.Many health department positions have traditionally included steps within certain job classifications that promote pay adjustments with increasing years of service. Career ladder approaches, however, specifically focus on providing opportunities for health continuing education, leadership development, or movement into formal leadership roles.Findings indicate that HDs have begun utilizing career ladders for professional development and critical role maintenance. Career ladders have been applied mostly for retention with limited impact on recruitment and increasing staff diversity. Challenges include civil service requirements, funding limitations, and complex recruitment that might exclude diverse candidates.This study emphasizes the importance of transparent development, engaging front-line staff, offering advancement pathways, and providing insights to enhance workforce recruitment and retention. The public health workforce plays a critical role in ensuring positive health outcomes for patients; however, workforce atrophy is a problem the field faces. Lack of viable advancement opportunities limits both recruitment and retention opportunities in public health systems. This study examined career ladders as a potential solution for recruitment and retention issues within public health agencies. Findings emphasize the challenges facing the public health workforce as well as opportunities for mitigation strategies in public health settings. The American public health workforce faces a crisis in both recruitment and retention of health workers, ranging from clinic staff and health care providers to billing and coding professionals and leadership executives. However, ensuring an efficient and sustainable workforce is a key factor in ensuring optimum public health outcomes For this study, we interviewed staff members in public health settings to assess challenges and opportunities for addressing recruitment and retention barriers. Findings from this study shed light on the ways in which public health systems are using career ladders for recruitment and retention.

BACKGROUND AND OBJECTIVES:To fully understand the impact of unintended pregnancy, as well as to evaluate the implementation and outcomes of programs targeted at reducing unintended pregnancy, it is critical that researchers be able to collect comprehensive data from health clinics that provide these services in vulnerable communities. METHODS:Our paper details recruitment and incentive strategies, as well as the theories that guided them, which allowed us to achieve a high survey response rate among health clinic administrators in public health clinics in 2 Southeastern states-South Carolina and Alabama-both of which have high rates of unintended pregnancy. RESULTS:Grounded in organizational theory, and utilizing the Tailored Design Method, we achieved a 68% response rate utilizing paper and web survey administration with multiple contact modes. Our incentive structure comprised both traditional cash-based and food-based incentives. CONCLUSIONS:Findings indicate high response rates are achievable despite high survey burden (ie, detailed information, length of survey). We found that sample screening was critical and that food-based incentives made an impression on respondents that positively impacted the researcher-respondent relationship. Providing detailed methodology and additional literature will assist researchers working with similar populations-a gap in the applied methodological literature that was problematic at the project's onset.

Objectives: Our aim was to explore postpartum individuals' experiences and perceptions of breastfeeding and International Board Certified Lactation Consultants' (IBCLC) knowledge and perceptions of maternity care practices and perceived barriers to breastfeeding among their patient populations in Appalachia. Methods: Semistructured interviews were conducted with seven IBCLCs and seven postpartum individuals. Interviews were recorded and transcribed. Thematic analysis was conducted to determine emergent themes and subthemes related to knowledge/perceptions, experiences, and barriers to breastfeeding among postpartum individuals, as well as emergent themes associated with the knowledge and perceptions of maternity care practices, easy-/difficult-to-implement Baby-Friendly Hospital Initiative maternity care practices, and perceived barriers to breastfeeding among IBCLCs. Results: Postpartum individuals recruited from an Appalachian obstetrics/gynecology clinic were aware of the benefits of breastfeeding, but their infant feeding journeys were more stressful than they expected, and they had limited access to lactation support and breastfeeding education/information. IBCLCs identified the benefits of the Baby-Friendly maternity care practices but mentioned some risks, especially when there is a lack of communication and coordination among providers. Environmental and informational barriers were identified by both postpartum individuals and IBCLCs as breastfeeding challenges potentially amenable to change. Conclusions: To support postpartum mothers in the Appalachian region, environmental barriers (eg, lack of lactation support) and informational barriers (eg, lack of prenatal education) need to be addressed.

IntroductionSexual assault nurse examiners are crucial care providers in cases of sexual assault. However, it is not clear whether sexual assault nurse examiner availability differs throughout the 13 states that comprise the Appalachian region of the United States. Therefore, this cross-sectional analysis identified sexual assault nurse examiner availability in 13 states and determined differences in availability by both county-level Appalachian status and county-level rurality status.MethodsData were downloaded from 2 public sexual assault nurse examiner registries for the included 13 states. Descriptive statistics of sexual assault nurse examiner certification type and availability by state were calculated. In addition, bivariate analyses of sexual assault nurse examiner availability by rurality and by Appalachian status were performed using 2-sample z-tests for equality of proportions.ResultsState-level sexual assault nurse examiner availability ranged from 0.34 to 0.86 sexual assault nurse examiners per 100,000 residents. Sexual assault nurse examiner availability in these 13 states did not differ by Appalachian status. However, rural areas had significantly lower sexual assault nurse examiner availability than urban areas in these 13 states.DiscussionThese data support previous literature on the need for stronger sexual assault nurse examiner programs in rural areas in the United States. Future research should take sexual assault prevalence into account to determine whether local sexual assault nurse examiner access needs, as well as appropriate support for sexual assault nurse examiners, are being met throughout Appalachian states.

Choose Well (CW) is a statewide contraceptive access initiative to reduce unintended pregnancy among patients utilizing federally funded family planning services. We examined CW's impact on contraceptive access at South Carolina federally qualified health centers from 2016 to 2019, which reported significantly higher increases in providing the full range of contraceptive methods and training onsite. CW prioritized ensuring change sustainability through obtaining funding and institutionalizing changes. (Am J Public Health. 2023;113(11):1167-1172. https://doi.org/10.2105/AJPH.2023.307384).

OBJECTIVES:Health insurance remains an important dimension of contraceptive access. This study investigated the role of insurance in contraceptive use, access, and quality in South Carolina and Alabama. METHODS:The study used a cross-sectional statewide representative survey that assessed reproductive health experiences and contraceptive use among reproductive-age women in South Carolina and Alabama. The primary outcomes were current contraceptive method use, barriers to access (inability to afford wanted method, delay/trouble obtaining wanted method), receipt of any contraceptive care in the past 12 months, and perceived quality of care. The independent variable was insurance type. Generalized linear models were applied to estimate prevalence ratios for each outcome's association with insurance type while adjusting for potentially confounding variables. RESULTS:Nearly 1 in 5 women (17.6%) was uninsured, and 1 in 4 women (25.3%) reported not using a contraceptive method at the time of the survey. Compared with women with private insurance, women with no insurance had a lower likelihood of current method use (adjusted prevalence ratio 0.75; 95% confidence interval 0.60-0.92) and receipt of contraceptive care in the past 12 months (adjusted prevalence ratio 0.61; 95% confidence interval 0.45-0.82). These women also were more likely to experience cost barriers to access care. The insurance type was not significantly associated with the interpersonal quality of contraceptive care. CONCLUSIONS:Findings highlight the need for expanding Medicaid in states that did not do so under the Patient Protection and Affordable Care Act, interventions to increase the number of providers who accept Medicaid patients, and protections to Title X funding as key elements for enhancing contraceptive access and population health outcomes.