HEALTH RISK
FACTORS

Pregnancy Vulnerability 

  • Poor Prenatal Care

  • Intrauterine Insults

  • Low Birth Weight and Prematurity 

Physical Health​

  • Neurodevelopmental Disorders 

  • Asthma & Allergies

  • Obesity & Hypertension

Mental Health​

  • Toxic Stress & PTSD

  • Substance Abuse

  • Violence & Crime

Art McCabe, JD, MBA, BA

City of Lawrence, Community Development Department, and Safe
and Successful Youth Initiative, Lawrence, Massachusetts, US

Community Garden to Fight Urban Youth Crime and Stabilize Neighborhoods

Chronic poor health within inner cities is usually the result of prolonged exposure to a multitude of health disparities. These disparities are exacerbated by poverty, high unemployment, crime, and youth violence. In many cases, these factors increase neighborhood instability and civic disengagement. Community garden programs can strengthen civic engagement and foster neighborhood stability, while simultaneously cutting down on youth violence. Community garden programs address the accumulation of health challenges in many ways and provide curative building blocks to deal with poor nutrition, obesity, diabetes, psychological disorders, and deficient growth of infants, substance abuse, civic detachment, and suicide rate. Urban agriculture not only strengthens communities from within but is also a cost-efficient, trans-generational cross-cultural, multi-disciplinary tool that can be used to address these issues. This article will summarize a rapidly growing body of research addressing the use of community gardens and the ways in which they can positively impact economic, social, and health-related aspects within inner cities. The article will draw upon the experience of the Neighborhood Community Garden Initiative implemented by Lawrence Massachusetts. The initiative is a community-based multi-pronged approach and demonstrates how lot revitalization and urban agriculture not only address health challenges but also effectively stabilizes distressed neighborhoods and is a cost-effective community-organizing tool. In turn, violence is reduced and residents feel safer, relations with police improve thereby lowering stress levels and empowering residents to take pride and ownership in the further development of their neighborhoods.

Meredith Martz, Rebecca Anthopolos, MA, Mara Geller, and Pamela J Maxson, PhD

Children‘s Environmental Health Initiative,
School of Natural Resources and Environment, University of Michigan, Ann Arbor, Michigan, Duke University, Durham, North Carolina, US

Pediatric Obesity and Food Access in Durham,

North Carolina

This project examines the relationship between the food environment and the prevalence of obesity among children within Durham County, North Carolina. Food retail data was used to classify food outlets into the following categories: large grocery, small grocery, convenience, and specialty. Density measures by block group for each type of food outlet were used to determine food access. Using health data from the Duke University Health System, Body Mass Index (BMI) levels were determined for patients within the sample. Multivariable logistic regression was performed to estimate the association of BMI levels with food outlet proximity. The results indicated that adolescents living in block groups with one specialty store were 22% more likely to be overweight or obese. Overall, the relationship between food access and childhood obesity in Durham County is subtle, with no consistent evidence suggesting that access to large and small supermarkets or convenience stores influences youth BMI.

Maureen Braun, MD, Brenda Levy, MD, Geoffrey Collins, MD and Leora Mogilner, MD

Department of Pediatrics, The Mount Sinai Medical Center, New York,

New York, US

Off the Mat: Piloting a Mindfulness-Based Curriculum with Adolescents in East Harlem

Stress is known to contribute to physical and mental health morbidity. Research in adults suggests that mindfulness-based practices (MBP) can reduce stress and improve physical, mental, and emotional well-being. Data on the effects of MBP in youth, however, is limited. Hypothesis: Teaching MBP to adolescents will reduce stress and improve coping ability. Methods: Ten weekly sessions were held, each including a discussion about a mindfulness-based theme, yoga, meditation, healthful snacks, and a health question and answer session. The Perceived Stress Scale (PSS-10) was administered pre and post-intervention to measure self-reported stress. Participants also completed pre/post-surveys about their attitudes toward doctors as well as a program evaluation. Paired t-
tests were used to analyze responses. Results: Fourteen female participants ages 12-17 enrolled with 100% completing all surveys. The pre and post-intervention mean PSS-10 scores were 28.9 and 25.6 respectively (p=0.053). Participants‘ feelings of nervousness and stress decreased (p = 0.027), confidence inability to handle personal problems increased (p = 0.048), and ability to control irritations increased (p=0.029). On a scale with 1=disagree, a lot, and 5=agree a lot, 100% of participants agreed that the program was of value to them (mean 4.9).
Conclusions: A MBP curriculum may increase coping ability and decrease feelings of stress in high-risk urban adolescents. Larger studies are needed to confirm these findings and to determine whether these changes will ultimately impact adolescent behaviors.

Pratibha Agarwal, MD, MPH, Beth Bailey, Ph.D., Jesi Hall, Michael Devoe, MD, and David Wood, MD, MPH

Department of Pediatrics and Department of Family Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee, USA 

Factors Associated with Maternal Drug Use and the Severity of Neonatal Abstinence Syndrome

East Tennessee and Middle Appalachia is the epicenter of the prescription drug epidemic, with approximately 15% of women giving birth at our institution documented as suffering from drug addiction. Objective: The objective of this study was to describe our sample of women giving birth to infants who were drug-exposed and experienced Neonatal Abstinence Syndrome (NAS) and to determine the maternal and neonatal factors associated with the severity of NAS as measured by the length of stay (LOS) in the Neonatal Intensive Care Unit (NICU). Methodology: This was a retrospective chart review of 73 infants diagnosed with NAS and treated in the NICU. We conducted bivariate analyses and multivariate modeling (least squares regression with backward elimination) of the significant variables (p < .10) against the infant’s LOS. Results: The mean LOS for infants with NAS was 17.7 days (sd = 11.6); 75.3% received nonpharmacological and 86.3% received pharmacologic (morphine) treatment. Of 73 women, 53.4% had a history of mental illness; 53.4% smoked >5 cigarettes
per day in the last trimester; 89% were taking buprenorphine, 9.6% had cord tissue positive for benzodiazepine. Term infants had 2.3 days longer LOS on average (p = 0.027) compared to preterm infants; infants exposed to benzodiazepines had 12.7 days longer LOS on average (p = 0.07) and prenatal exposure to >5 cigarettes per day in the last trimester increased the hospital stay by 6.4 days (p = 0.022). Conclusion: We found that exposure to benzodiazepines and cigarette smoking were associated with an increased LOS.

Lea Redd, BA, Ren Belcher, BA,

Brianne Dotts, JD,
and Bree Andrews, MD, MPH

Section of Neonatology, Department of Pediatrics, Biological Sciences Division,
The University of Chicago, Chicago, IL, USA
Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA
The Chicago Medical-Legal Partnership for Children, a program of Legal Counsel for Health Justice, Chicago, IL, USA

A Silver Lining for Neonatal Intensive Care (NICU) Graduates: Coordinated Services from 0-6 Years

The objective of this project was to implement preventative medical-legal consultations using an enhanced neonatal team consisting of a pediatrician, social worker, and lawyer for improved access to public benefits, and to evaluate its success using metrics of parent and child functioning over
time. Methods: NICU graduates, as patients at the Center for Healthy Families at the University of Chicago (CHF), were enrolled in the Silver Linings Project after screening when a disconnect between public benefits and developmental and financial needs was identified. At their regularly scheduled pediatrician visits, a legal advocate from the Chicago Medical-Legal Partnership for Children (CMLPC) worked with the medical team during the consultation to build an action plan to improve access and utilization of public benefits. Within a year of enrollment, action plans were reviewed, measuring progress on action items in three domains: family items, medical items, and legal items. Results: Twenty-five families participated in this program over 18 months. The physicians, lawyers, and parents completed 80% of the total action items across the sample.
Completion of these action items resulted in improved access compared to the time of enrollment in Early Intervention (EI), food benefits (SNAP and WIC) and
Individualized Educational Plans (IEP) for children involved. Conclusions: A preventative strategy to reduce social barriers for NICU graduates using a medical-legal consultation and action plan is feasible and effective at improving access to public benefits and decreasing reported parental stress.

Colleen Clark, MPH Candidate, and Kimberly Price, PhD, MCHES

Center for Graduate Studies of Asheville, Program of Public Health, Lenoir-Rhyne University, Asheville North Carolina, USA

Exploring the Role of Social Support in Understanding Barriers to Breastfeeding Practices for Adolescent Mothers

Although breastfeeding has many nutritional, immune-logical, and positive health outcomes for both mother and infant, the prevalence of breastfeeding among adolescent mothers is low. Understanding the needs of this vulnerable
population and the obstacles they face could assist in the development of health promotion strategies and lead to greater participation in breastfeeding practices. The purpose of this study is to understand the role of social support in
adolescent mother’s breastfeeding practices. Adolescent mothers were recruited at community agencies that implement a North Carolina Health and Human Services funded Adolescent Parenting Program (APP). The project
focuses on the breastfeeding experiences of APP participants in Western North Carolina, part of the Southern Appalachian region. Participants completed a self-report survey regarding their breastfeeding experiences. Of the 16 participants, most (87.5%) attended a prenatal class where breastfeeding was discussed and most (75%) initiated breastfeeding their infants, while only 12.5% sustained a breastfeeding practice past 4 months. Few felt comfortable breastfeeding at work (31%) or at school (43.8%). All mothers had a healthcare
provider or someone at the hospital speak to them about breastfeeding. Perceptions of social support were gathered using the ESSI instrument, validated in cardiac patients. Mothers reported that they had “someone available” to them who showed them “love and affection” (M = 4.625 on 5 point scale). A mother’s interpersonal relationship with her healthcare provider, family, and peers can help cultivate empowerment in order for her to navigate the challenges of breastfeeding and directly improve the long-term health outcomes for both the mother and child.

Hope Bentley, Jannett Lewis-Clark, OTD,
MOT, OTR/L, CLT, Alfonso Robinson Jr,
Brittany McCullough, Vanessa Harris,
Kayla Bryan, Precious Harris, Teralesha Baity, and Chante’ Warner

Occupational Therapy Program, School of Nursing and Allied Health, Tuskegee University, Tuskegee, Alabama, USA

A Community-based Program to Decrease the Risk of Childhood Obesity

In the United States 80% of obese adolescents, 50% of obese preschool-aged children, and 50% of school-aged children are prone to develop adult obesity. Health education and physical activity for children at risk for obesity are key to mitigating the risk of developing obesity as an adult. Health education and physical activity complement each other, improving children’s behaviors and
attitudes towards health. This study builds upon an existing body of knowledge about the prevention of obesity and long-term morbidity among rural youth from disadvantaged backgrounds. The purpose of this study was to improve the
attitudes and behaviors towards healthy eating through combining health education and physical activity among children of Macon County, Alabama. We conducted a mixed-method design with a cluster sample of 11 participants. We used a pre/posttest lifestyle student-created questionnaire guided by the Institut de Recherches Cliniques de Montréal (IRCM) lifestyle questionnaire and the Simple Lifestyle Indicator Questionnaire to characterize health behaviors (i.e., consumed vegetables, fruits, sweet drinks, and water) and attitudes (i.e., enjoyment of exercise, emotional eating, ways of staying active when the weather is bad). Our study concluded that interactive health education and physical activity interventions positively influenced healthy eating behaviors and attitudes in nine out of eleven participants for attitudes and six out of eleven
participants for behaviors on healthy eating.

Candace Tannis, MD, MPH, Rachel Fletcher-Slater, MPH, Inessa Lopez, MPH, Alexandrah Gichingiri, BS, Mario Cassara, MPH, Susanne Lachapelle, RN, and Elizabeth Garland, MD, MS

Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai and LSA Family Health Services, New York, USA

Risk Factors for Preeclampsia in a High-Risk Cohort

of Women Served by a Nursing-based Home Visiting Program

This descriptive study aimed to identify the impact of psychosocial risk factors on pregnancy outcomes for high-risk women in an urban setting. Women in this category tend to experience adverse pregnancy outcomes, like preeclampsia, at greater rates than low or medium-risk women. A retrospective paper chart review of East Harlem women served by the LSA Family Health Service (LSA) Maternal Outreach Program (MOP) was conducted. All women who enrolled in the MOP with a singleton pregnancy from January 2015 to December 2017, were
eligible for inclusion in our analyses. Data were analyzed using SPSS (version 23). Of 379 total participants, 68.6% (n = 203) were Hispanic/Latina women, 44.8% (n = 163) were English only speakers, 67.4% (n = 226) were identified as overweight/obese, 90.6% (n = 328) were mothers over the age of 20 among those for whom data were available. Sixty-two percent (n = 235) initiated prenatal care in their first trimester, and 71.5% (n = 271) were referred to the MOP by a hospital or other healthcare provider. The percentage of preeclampsia among mothers was 26.9% (n = 102). After adjustment for type of LSA services received, and race/ethnicity, there were no associations between psychosocial risk factors and preeclampsia diagnosis in this population. Further research is needed on the relationship between psychosocial risk factors and preeclampsia to identify potential areas of intervention and reduce the burden of disease.

Ivorie Stanley, MD, MPH, and Susan Buchanan, MD, MPH

The University of Illinois at Chicago, School of Public Health, Division of Environmental and Occupational Health Sciences, Chicago, Illinois, USA

Evaluating Fish-consumption in Pregnancy: An Opportunity for Neurodevelopmental Health Promotion

For children particularly burdened by social and economic disadvantages, exposure to toxic substances is an important contributor to adverse health outcomes and health disparities. Maternal consumption of fish high in methylmercury during pregnancy is associated with increased risks for preterm delivery and adverse neurodevelopmental outcomes in children. The aim of this project was to evaluate a single fish consumption screening question to identify pregnant women at risk for elevated mercury levels. The question “In general, do you eat more than two fish meals per week?” was asked and a single test for total blood mercury level was obtained from pregnant women presenting to an urban hospital Labor and Delivery Triage Unit. In this limited study (n=42), participants were mainly Black (48%) and Latina (43%), and 71.4% had a median household income (estimated from zip code) below 200% of the federal poverty level. No participant had an elevated mercury level. Indeed, this population had a very low geometric mean mercury level of 0.32 μg/L (64% below the US geometric mean for women of childbearing age; from NHANES 2009-2010), indicating a likely low frequency of fish intake. In this sample population, prenatal exposure to elevated methylmercury was not an issue and the utility of this screening question was not supported. However, in these women already at risk for disparate health outcomes, the potential health benefits for brain development from omega -3 fatty acids in fish are being missed.

Danielle Dimacali, BS,
Claribel Marmol, BS, MPH, Jalisa Fortune, BIS,
Jeannie Rodriguez, PhD, RN, C-PNP/PC, and Helen Baker, PhD, MSc, FNP-BC

Nell Hodgson Woodruff School of Nursing,
Emory University, Atlanta, Georgia, USA

Barriers and Promoters to Initiating and Sustaining
Breastfeeding Among African American Women

According to the Centers for Disease Control and Prevention statistics, African American women are less likely to breastfeed compared to other racial/ethnic groups. Just over 60% of African American mothers initiate breastfeeding, with only 14% continuing to exclusively breastfeed until their infant is 6 months of age. Despite this persistent disparity, few studies have explored the barriers and promoters to initiating and sustaining breastfeeding specific to African American women. Objective: This study uses a “positive deviant” model to help understand the factors that have influenced the experiences of African American mothers who have exclusively breastfed for at least six months. Methods: Ten African American women who had given birth within the previous year were recruited through a lactation center located in the southeastern region of Atlanta, GA. Semi-structured interviews were conducted with these women regarding the initiation and sustaining of breastfeeding for six months or longer, as well as the social,
cultural, environmental, and economic factors that may have acted as barriers and/or promoters to breastfeeding. Interviews were transcribed and general qualitative data analyses using MaxQDA utilizing intra-and inter-rater reliability techniques were carried out. Results: The majority of the participants described the following as positive factors: supportive family, workplace autonomy,
and support groups. Barriers included: long commute, work hours, stressful environments, and difficulty latching. Conclusion: This group of African American women is positive deviants and key informants in identifying barriers and promoters of exclusively breastfeeding for at least six months. Our findings will help generate hypotheses on community and culturally tailored interventions to
encourage more African American mothers to initiate and sustain breastfeeding.

April L Brown, MA, MPH, Broome G McKenna, BA, Madeleine F Cohen, BA, Anna L Dunlop, MD, MPH, Elizabeth J Corwin, RN, PhD, and Patricia A Brennan, PhD 

Department of Psychology, Emory University,
Atlanta, Georgia, USA

Nell Hodgson Woodruff School of Nursing,
Emory University, Atlanta, Georgia, USA

Maternal childhood adversity and early parenting:
Implications for infant neurodevelopment

This study aimed to examine associations between maternal childhood abuse and maltreatment, early parenting behaviors, and infant neurodevelopment among African American mother-infant dyads. Maternal adverse childhood experiences (ACEs) were assessed during pregnancy using the Childhood Trauma Questionnaire, and early parenting behaviors were assessed by coding videotaped observations using an adapted version of The Three-Bag Assessment

when infants were 3-months of age. Infant neurodevelopment was assessed using the cognitive and motor subscales of the Bayley Scales of Infant and Toddler
Development. At the time of this analysis, 59 mother-infant dyads had ACEs exposure, early parenting, and infant neurodevelopment data available from the infant 3-month assessment. Preliminary findings suggest no main effects of maternal adversity on infant neurodevelopment and indicated no significant interaction effects between maternal adversity and early parenting behaviors, although this study may have been underpowered to detect a small effect given the sample size available. It is still possible that these factors predict the rate of neurodevelopment beyond the first three months of life, which will be examined
using growth curve analyses in future studies. The overall goal of this ongoing research is to explore parenting behaviors as a key point of intervention that may reduce the intergenerational impact of ACEs on child neurodevelopmental outcomes, thereby breaking the cycle of risk.

Rebecca J Graves, PhD, NP-C, Leigh A Minchew, DNP, RN, WHNP-BC, PMHNP-BC, Sonia Smith, DNP, CPNP/ CNS, Kimberly Zlomke, PhD, BCBA-D, Kristina Caffey, Bridget Owens, BA, Anna Thies, BSN, Megan Gibery, and Sharon M Fruh, PhD, FNP-BC

College of Nursing and School of Psychology,
University of South Alabama, Mobile, Alabama, USA

Breaking the Cycle: Changing Sleep Habits to Decrease Obesity 

This study evaluated the sleep characteristics of children from a low-income urban area and the barriers these children have in developing healthy sleep behaviors.
Methods: A multiphase mixed-methods exploratory research design was used to provide a deeper understanding of the perceptions of parents/caregivers from low-income urban areas regarding their children’s sleep. Results: Sleep was identified as a “very important” contribution to their children’s health by 97.1% of participants (options being “not important”, “somewhat important”, and “very
important”); however, a high proportion reported a home environment that is not conducive to healthy, restful sleep. Problematic sleep habits of children, including
parasomnias, sleep anxiety, and night wakening, were noted by 88.2% of the participants on the Children's Sleep Habits Questionnaire. Focus groups identified several barriers to healthy sleep hygiene practices such as television/
electronics before bedtime, co-sleeping, and night waking (paired with eating/drinking). During the focus groups, many parents/caregivers reported daytime tiredness and the drowsiness of their children. Discussion: Culturally-
appropriate education is needed to guide parents/caregivers in creating a healthy home sleep environment. Simple measures such as removing televisions from bedrooms and discontinuing electronic use before bedtime, night waking food/beverage feeding, and co-sleeping may lead to the increased occurrence of healthy sleep with this population. Culturally appropriate education may be an essential element to helping this community learn strategies for creating a healthy home environment that promotes optimal sleep habits.

Rebecca J Graves, PhD, NP-C, Leigh A Minchew, DNP, RN, WHNP-BC, PMHNP-BC, Sonia Smith, DNP, CPNP/ CNS, Kimberly Zlomke, PhD, BCBA-D, Kristina Caffey, Bridget Owens, BA, Anna Thies, BSN, Megan Gibery, and Sharon M Fruh, PhD, FNP-BC

College of Nursing and School of Psychology,
University of South Alabama, Mobile, Alabama, USA

Breaking the Cycle: Changing Sleep Habits to Decrease Obesity 

This study evaluated the sleep characteristics of children from a low-income urban area and the barriers these children have in developing healthy sleep behaviors.
Methods: A multiphase mixed-methods exploratory research design was used to provide a deeper understanding of the perceptions of parents/caregivers from low-income urban areas regarding their children’s sleep. Results: Sleep was identified as a “very important” contribution to their children’s health by 97.1% of participants (options being “not important”, “somewhat important”, and “very
important”); however, a high proportion reported a home environment that is not conducive to healthy, restful sleep. Problematic sleep habits of children, including
parasomnias, sleep anxiety, and night wakening, were noted by 88.2% of the participants on the Children's Sleep Habits Questionnaire. Focus groups identified several barriers to healthy sleep hygiene practices such as television/
electronics before bedtime, co-sleeping, and night waking (paired with eating/drinking). During the focus groups, many parents/caregivers reported daytime tiredness and the drowsiness of their children. Discussion: Culturally-
appropriate education is needed to guide parents/caregivers in creating a healthy home sleep environment. Simple measures such as removing televisions from bedrooms and discontinuing electronic use before bedtime, night waking food/beverage feeding, and co-sleeping may lead to the increased occurrence of healthy sleep with this population. Culturally appropriate education may be an essential element to helping this community learn strategies for creating a healthy home environment that promotes optimal sleep habits.

Brennan Rhodes-Bratton, MPH, Andrew Rundle, DrPH, Gina S Lovasi, PhD, MPH, and Julie Herbstman, PhD

Department of Sociomedical Sciences
Department of Epidemiology, Columbia University, Mailman School of Public Health, New York, NY, USA
Department of Epidemiology and Biostatistics, Drexel University, Dornsife School of Public Health, Urban Health Collaborative, Philadelphia, PA, USA
Pennsylvania

Department of Environmental Health
Sciences, Columbia University, Mailman School of Public Health, New York, NY, USA

The Relationship Between Childhood Obesity and Neighborhood Food Ecology Explored Through the Context of Gentrification in New York City

Inequity and health disparities can be exacerbated as a result of gentrification when long-term residents are displaced, or remain but are not able to take advantage of new opportunities. The disappearance of old and the emergence
of new food establishments may increase the proximity to and density of healthy food options, however, affordability and consumption of healthy food, nor a decrease in risk of adverse health outcomes are not guaranteed. Our study aims
to understand the relationship between gentrification, neighborhood food ecology, and childhood obesity. We describe food opportunities changes in New York City using National Establishments Time Series Database stratified by gentrification status. Using data from the Columbia Center for Children’s Environmental Health birth cohort study, we evaluate the impact of the neighborhood-level changing food chances on the body mass index z- scores of children at age five. Overall, gentrifying neighborhoods have the highest number of food chances and experience the most substantial increase in both healthy
(p < 0.001) and unhealthy (p < 0.001) food chances between 1990-2010. After adjusting for covariates, higher access to healthy food chances was associated with both lower BMI z-score (p < 0.01) and less likelihood of being overweight or obese (p < 0.001) for five-year-old children. Our results suggest gentrification was associated with contemporaneous changes in the neighborhood food chances in NYC and children exposed to greater healthy foods experienced a protective effect against obesity developed by five years old. Further research is needed to

understand other potential pathways connecting gentrification to childhood BMI.

Jordyn A Gunville, MPH, and Jessica Williams, PhD, MA

Center for American Indian Community Health
Department of Family Medicine and Community Health
Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas, USA

The Development of a Prenatal Care Health Literacy Instrument for American Indian Mothers

American Indian (AI) women are nearly four times as likely as white women to experienced delayed prenatal care until the third trimester. Additionally, AI are the only racial/ethnic group that has not had a decline in infant mortality between 2005 and 2014. While these inequities are apparent, little is known about health literacy among AI women of childbearing age. Existing health literacy instruments do not take the cultural context surrounding the prenatal period. Method: After a comprehensive review of the literature of health literacy tools and questionnaires, a measure of prenatal care health literacy for AI mothers was developed with four topic domains. Measure development was iterative. Cognitive interviews, a standard technique to assist validation, were used to verify the face validity of the
instrument and to check understanding in the population of interest. Results: The initial instrument had 60 questions. Iterative review by experts in population health and AI health disparity research eliminated 30 questions that were duplicative. Cognitive interviews were conducted with AI researchers and community members, after which 5 more questions were eliminated. These interviews also help establish the validity of the tool, understanding of the questions, and suggestions for the formatting of the instruments. The final instrument consists of 25 questions. Discussion: Health literacy is the ability to obtain, process, and understand health information to make knowledgeable health decisions. There is little information on health literacy specific to prenatal care and infant health among AI. This instrument was developed specifically for this marginalized population.

Cristian Quizhpi1,
, MD,
Karen Schetzina1

, MD, MPH,

Gayatri Jaishankar1
, MD,
Robert Matthew Tolliver1
, PhD,

Deborah Thibeault2

, DSW, LCSW,

Hakyong Gloria Kwak1
, BS,

Olushola Fapo
1
, MD, MPH,

Jennifer Gibson1

, MD, Katie Duvall1
, MA,

and David Wood1

, MD, MPH

Jordyn A Gunville, MPH, and Jessica Williams, PhD, MA

Breaking the Cycle of Childhood Adversity Through Pediatric Primary Care Screening and Interventions: A Pilot Study

American Indian (AI) women are nearly four times as likely as white women to experienced delayed prenatal care until the third trimester. Additionally, AI are the only racial/ethnic group that has not had a decline in infant mortality between 2005 and 2014. While these inequities are apparent, little is known about health literacy among AI women of childbearing age. Existing health literacy instruments do not take the cultural context surrounding the prenatal period. Method: After a comprehensive review of the literature of health literacy tools and questionnaires, a measure of prenatal care health literacy for AI mothers was developed with four topic domains. Measure development was iterative. Cognitive interviews, a standard technique to assist validation, were used to verify the face validity of the
instrument and to check understanding in the population of interest. Results: The initial instrument had 60 questions. Iterative review by experts in population health and AI health disparity research eliminated 30 questions that were duplicative. Cognitive interviews were conducted with AI researchers and community members, after which 5 more questions were eliminated. These interviews also help establish the validity of the tool, understanding of the questions, and suggestions for the formatting of the instruments. The final instrument consists of 25 questions. Discussion: Health literacy is the ability to obtain, process, and understand health information to make knowledgeable health decisions. There is little information on health literacy specific to prenatal care and infant health among AI. This instrument was developed specifically for this marginalized population.

Department of Pediatrics,
East Tennessee State University, USA
Department of Social Work, East Tennessee State University, ETSU College of Public Health, Johnson City, Tennessee, USA