Publications

Abstract

Aims: To conduct a comparative analysis of four cohorts of newly licensed Registered Nurses and their work schedule, daily shift length, weekly work hours, second job, and weekly overtime hours. Nurses also reported their preferences regarding work schedule and daily shift length. Design: We used a retrospective, comparative design analysing four cross-sectional surveys from new nurses first licensed between 2004–2015. Methods: Using state licensure lists, nurses who were first licensed between 1 August 2004 and 31 July 2005 were randomly sampled using a nested design in 23 geographical areas in 13 states and Washington, DC. The same sampling strategy was conducted for subsequent cohorts in January 2009, 2012, and 2016. We sent a mailed survey measuring demographics, education, work attributes, and attitudes to participants with a $5 incentive, following methods by Dillman. Results: There were no statistically significant differences in average weekly work hours (39.4 hrs) or holding more than one job for pay (11.6–14.6% across all cohorts). There were statistically significant differences in overtime across cohorts and shift length by unit type. The preferred shift length was 12 hrs and day shift was the preferred work schedule. Conclusion: New nurses are predominantly scheduled for 12-hrs shifts and nearly half work weekly overtime, trends that have remained relatively stable over the past 10 years. Nurse managers, policy-makers, and researchers should pay attention to new nurses’ schedule and shift preferences and guard against mandatory overtime hours.

Abstract

The purpose of this article is to describe the process used to create a conceptual-theoretical-empirical structure for a proposed study of policies for home health care nursing services for informal caregivers of persons with Alzheimer disease. The process consisted of linkage of the Conceptual Model of Nursing and Health Policy with Roy’s Adaptation Model to guide derivation of a middle-range theory of home health care nursing services for Alzheimer disease informal caregiving, and selection of appropriate empirical research methods.

Abstract

The purpose of this paper is to present a stepwise, multi-construct, innovative framework that supports the use of eHealth technology to reach sexual minority populations of color to establish trustworthiness and build trust. The salience of eHealth interventions can be leveraged to minimize the existing paradigm of medical mistrust among sexual minority populations of color living with chronic illnesses. These interventions include virtual environments and avatar-led eHealth videos, which address psychosocial and structural-level challenges related to mistrust. Our proposed framework addresses how eHealth interventions enable technology adoption and usage, anonymity, co-presence, self-disclosure, and social support and establish trustworthiness and build trust.

Abstract

The ongoing discourse on LGBTQ health has been centered on improving patient outcomes; little attention is given to exploring the experiences of LGBTQ healthcare professionals. This article offers an actionable discussion on how to create an LGBTQ-inclusive work environment for all healthcare workers.

Abstract

Multimorbidity affects 75% of older adults (aged 65 years and older) in the United States and increases risk of poor medical outcomes, especially among the poor and underserved. The creation of a Medicaid option allowing states to establish health homes under the Affordable Care Act was intended to enhance coordinated care for Medicaid beneficiaries with multimorbidity. The Community-Based Health Home (CBHH) model uses the infrastructure of the Adult Day Health Center (ADHC) to serve as a health home to improve outcomes for medically complex vulnerable adults. Between 2017 and 2018, we used a sequential explanatory mixed-methods approach to (a) quantitatively examine changes in depression, fall risk, loneliness, cognitive function, nutritional risk, pain classification, and health care utilization over the course of 12 months in the program and (b) qualitatively explore the perspectives of key stakeholders (registered nurse navigators, participants, ADHC administrators, and caregivers) to identify the most effective components of CBHH. Using data integration techniques, we identified components of CBHH that were most likely driving outcomes. After 12 months in CBHH, our racially diverse sample (N = 126), experienced statistically significant (p < .05) reductions in loneliness, depression, nutritional risk, poorly controlled pain, and emergency department utilization. Stakeholders who were interviewed (n = 40) attributed positive changes to early clinical intervention by the registered nurse navigators, communication with providers across settings, and a focus on social determinants of health, in conjunction with social stimulation and engagement provided by the ADHC. CBHH positions the ADHC as the locus of an effective health home site and is associated with favorable results. CBHH also demonstrates the unique capacity and skill of registered nurses in integrating health and social services across community settings. Continued exploration of CBHH among diverse populations with multimorbidity is warranted.

Abstract

Background: A large proportion of our older adults live with Alzheimer’s disease and related dementias, and the number of those diagnosed in the future is expected to increase dramatically as the population ages. Persons with dementia bring unique healthcare challenges due to the manifestation of behavioral and psychological symptoms associated with the disease. The lack of geriatric clinicians as well as a properly trained non-geriatric specialist workforce capable of addressing the symptoms persons with dementia exacerbates the challenge of providing effective care. Pharmacological interventions are contraindicated for treatment of most behavioral psychological symptoms of dementia (BPSD). The Centers for Medicare and Medicaid Services now requires that nonpharmacological interventions be used as a first-line treatment. It has not been determined what nonpharmacological intervention for BPSD are most effective and what the infrastructure would entail for such interventions for PWD living at home. Purpose of Review: The purpose of this study is to examine the literature focusing on interventions aimed towards managing persons’ symptoms of dementia living in home-based settings. A scoping review examining the literature published on this topic over the last 3 years was conducted. Recent Findings: One thousand twenty-four articles were found, of which nine met inclusion criteria. Five articles used occupation-based therapy, two used exercise therapy, and one article was found utilizing aromatherapy and music therapy. Summary: The majority of articles used occupation-based therapy as their intervention for BPSD. Overall, research showed nonpharmacological interventions can be effective in helping mange BPSD in persons living in home-based settings, although maintenance effects of interventions should be further explored in future research as well as how to ensure these interventions are more widely utilized by caregivers in this setting.

Abstract

Missed nursing care is an important measure of nursing care quality that is sensitive to nurse staffing and is associated with patient outcomes in medical-surgical and pediatric inpatient settings. Missed nursing care during labor and birth has not been studied, yet childbirth represents the most common reason for hospitalization in the United States. The Missed Nursing Care (MISSCARE) Survey, a measure of medical-surgical nursing quality with substantial evidence for validity and reliability, was adapted to maternity nursing care using data from focus groups of labor nurses, physicians, and new mothers and an online survey of labor nurses. Content validity was evaluated via participant feedback, and exploratory factor analysis was performed to identify the factor structure of the instrument. The modified version, the Perinatal Missed Care Survey, appears to be a feasible and promising instrument with which to evaluate missed nursing care of women during labor and birth in hospitals.

Abstract

Background: The highest rates of new HIV infections are observed in African Americans and Hispanics/Latinos (ethnic minority) adolescents and young adults (youth). HIV-infected ethnic minority youth are less likely to initiate and maintain adherence to antiretroviral treatment (ART) and medical care, as compared with their adult counterparts. Objective: The objective of this research protocol was to describe our proposed methods for testing a peer-led mobile health cognitive behavioral intervention, delivered via remote videoconferencing and smartphones with HIV-infected ethnic minority youth, Adherence Connection for Counseling, Education, and Support (ACCESS). Our secondary aim was to obtain initial estimates of the biobehavioral impact of ACCESS on HIV virologic outcomes and self-reported ART adherence, beliefs and knowledge about ART treatment, adherence self-efficacy, and health care utilization (retention in care). Methods: An exploratory, sequential mixed-methods study design will be used with conceptual determinants of adherence behavior informed by the information-motivation-behavioral skills model. HIV-infected ethnic minority youth aged 16 to 29 years with a detectable HIV serum viral load of more than 200 copies/ml (N=25) will be recruited. Qualitative pretesting will be conducted, including semistructured, in-depth, individual interviews with a convenience sample meeting the study inclusion criteria. Preliminary analysis of qualitative data will be used to inform and tailor the ACCESS intervention. Testing and implementation will include a one-group pre-posttest pilot, delivered by a trained successful peer health coach who lives with HIV and is well-engaged in HIV care and taking ART. A total of 5 peer-led remote videoconferencing sessions will be delivered using study-funded smartphones and targeting adherence information (HIV knowledge), motivation (beliefs and perceptions), and behavioral skills (self-efficacy). Participant satisfaction will be assessed with poststudy focus groups and quantitative survey methodology. Bivariate analyses will be computed to compare pre- and postintervention changes in HIV biomarkers, self-reported ART adherence, beliefs and knowledge about ART, adherence self-efficacy, and retention in care. Results: As of December 2018, we are in the data analysis phase of this pilot and anticipate completion with dissemination of final study findings by spring/summer 2019. The major outcomes will include intervention feasibility, acceptability, and preliminary evidence of impact on serum HIV RNA quantitative viral load (primary adherence outcome variable). Self-reported ART adherence and retention in care will be assessed as secondary outcomes. Findings from the qualitative pretesting will contribute to an improved understanding of adherence behavior. Conclusions: Should the ACCESS intervention prove feasible and acceptable, this research protocol will contribute to a shift in existent HIV research paradigms by offering a blueprint for technology-enabled peer-led interventions and models.

Abstract

Objective: To evaluate the degree to which registered nurses perceive their labor and delivery units to be adhering to Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) staffing guidelines. Design: Prospective, cross-sectional study via an online survey of labor nurses recruited from hospitals in three states. Setting/Local Problem: In late 2016 and early 2017, labor nurses in selected hospitals in California, Michigan, and New Jersey were contacted via e-mail invitation to participate in a study about nursing care during labor and birth. Nurse leaders in each hospital facilitated the invitations. Participants: A total of 615 labor nurses from 67 hospitals. Intervention/Measurements: Descriptive statistics and linear regression models were used for data analysis. Results: Most nurses reported that the AWHONN nurse staffing guidelines were frequently or always followed in all aspects of care surveyed. Hospitals with annual birth volumes of 500 to 999 range were significantly more likely than hospitals with 2,500 or more annual births to be perceived as compliant with AWHONN staffing guidelines. Conclusion: When the AWHONN staffing guidelines were first published in 2010, there was concern among some nurse leaders that they would not be adopted into clinical practice, yet nurses in our sample overwhelmingly perceived their hospitals to be guideline compliant. There remains much more work to be done to determine nurse-sensitive outcomes for maternity care and to ensure that all women in labor in the United States are cared for by nurses who are not overburdened or distracted by being assigned more women than can be safely handled. In our survey of 615 labor nurses, most reported that the AWHONN nurse staffing guidelines were frequently or always followed in all aspects of care surveyed.

Abstract

Background: “Drug checking” has become a common harm reduction method used to test illicit substances, such as ecstasy, for purity and/or the presence of adulterants. Formal drug-checking services have been operating for decades, and the use of personal reagent test kits appears to be relatively common; however, little attention has been devoted to understanding the role and broader experiences of ‘drug-checkers’ (i.e., people who test their own and/or other people's substances). As such, it remains unknown who is engaging in this practice, their motivations for drug-checking, and what barriers they may experience. We addressed this research gap by interviewing people who check drugs about their experiences, with a goal of better understanding drug checking practices. Methods: We conducted in-depth interviews with 32 adults in North America who reported testing drugs. Coding was conducted in an inductive manner and thematic analysis was used to identify relevant themes. Results: Over half (56.2%) of our sample was affiliated with a drug checking organization. Among non-affiliated checkers (43.8%), the majority (57.1%) tested for friends, 21.4% tested only for themselves, and 21.4% were people who sold drugs and tested for their clients. Motivations were driven largely by altruism, described by checkers as wanting to protect their peers from exposure to adulterants. People interviewed who sold drugs were altruistic in the same manner. Barriers to checking—particularly at nightclubs and festivals—included perceived illegality of test kits and denied approval to test drugs at venues, although many checkers circumvented this barrier by checking drugs without such approval. Conclusions: Drug checkers in North America seek to educate people who use drugs about the risk of exposure to unexpected substance types, but they face various barriers. Policy change could help ensure that these potentially life-saving services can be provided without fear of fines and/or criminal prosecution.

Abstract

Objectives: To explore advance directive (AD) preferences and the facilitators and barriers of promoting ADs among terminally ill older patients in China. Design: A scoping review was used to identify key themes in ADs. Setting and participants: Studies from 2007 to 2017 were identified from the MEDLINE and Cochrane libraries. Articles concerning important components of ADs in terminally ill older patients were selected. Measures: Eligible articles concerning important components of ADs in terminally ill older patients were thematically synthesized. Later, implementation evidence was identified from core components. Results: We used 13 articles and identified key components in ADs: (1) Chinese cultural characteristics; (2) policy support; (3) advance care planning (ACP); (4) hospice-palliative care (HPC); (5) prognosis disclosure and life-sustaining treatment preference; (6) knowledge about ADs for patients and their families; (7) the prevalence of ADs; (8) implementation of ADs; (9) staff experience and training; and (10) effective communication between patients, their families, and health care professionals. Facilitators in implementing ADs included previous comfort-oriented end-of-life care experience of patients or their families, and the enactment of relevant policy. Barriers included traditional Chinese cultural beliefs; lack of policy; lack of knowledge of ADs, ACP, and HPC; and poor communication between physicians, patients, and family members. Conclusions/Implications: Chinese patients still showed positive preferences toward ADs. The implementation of ADs could be promoted through public education about ADs, the learning of ACP and HPC, and relevant policy development in China.

Abstract

To support the development of internationally comparable common data elements (CDEs) that can be used to measure essential aspects of long-term care (LTC) across low-, middle-, and high-income countries, a group of researchers in medicine, nursing, behavioral, and social sciences from 21 different countries have joined forces and launched the Worldwide Elements to Harmonize Research in LTC Living Environments (WE-THRIVE) initiative. This initiative aims to develop a common data infrastructure for international use across the domains of organizational context, workforce and staffing, person-centered care, and care outcomes, as these are critical to LTC quality, experiences, and outcomes. This article reports measurement recommendations for the care outcomes domain, focusing on previously prioritized care outcomes concepts of well-being, quality of life (QoL), and personhood for residents in LTC. Through literature review and expert ranking, we recommend nine measures of well-being, QoL, and personhood, as a basis for developing CDEs for long-term care outcomes across countries. Data in LTC have often included deficit-oriented measures; while important, reductions do not necessarily mean that residents are concurrently experiencing well-being. Enhancing measurement efforts with the inclusion of these positive LTC outcomes across countries would facilitate international LTC research and align with global shifts toward healthy aging and person-centered LTC models.

Abstract

Objective: A lack of education among migrants remains an important but overlooked issue that indirectly contributes to HIV transmission. It is necessary to know who has received HIV education and who has a lower probability of being educated among migrants across different regions and age groups in China. Methods: We used pooled data from the 2014 and 2015 Migrants Population Dynamic Monitoring Survey. The study population included 406,937 Chinese migrants. Participants were asked whether they had received any HIV education after migrating to the destination city. Regions were categorized into east-coast, central, northwest, southwest, west-Tibet, west-Uyghur, and northeast regions. Hierarchical logistic regression modeling was conducted to investigate the relationships between the independent variables and HIV education. Results: Of 406,937 participants, half (50.6%) had reported receiving HIV education. Individuals in the west-Uyghur region had the highest proportion of receiving HIV education (73.0%), followed by the southwest region (67.9%) and the west-Tibet region (54.8%). Methods of receiving HIV education varied among different age groups. Individuals who were in a region with a higher prevalence of HIV, a lower density of medical professionals, and a higher density of migrants were more likely to receive HIV education. Conclusions: The study showed significant regional disparities among migrants in China. More HIV resources need to be allocated to regions with large-scale floating populations, such as the east-coast region. Providing multiple options, including both new and traditional media, for both young and elderly migrants is essential. HIV education should be tailored to the age of migrants with low educational and income levels.

Abstract

Few studies have examined the relationship between sexually transmitted infections (STIs) and preterm birth (<37 weeks gestation) by subtype (<32 weeks, 32-36 weeks, spontaneous, provider-initiated). Here, we evaluate the odds of preterm (by subtype) and early-term (37 and 38 weeks gestation) birth in women with an STI compared with a propensity score-matched reference population. Methods The sample was selected from California births in 2007 to 2012. Sexually transmitted infection was defined as a maternal diagnosis of chlamydia, gonorrhea, or syphilis in the birth certificate or hospital discharge record. A reference sample of women without an STI was selected using exact propensity score matching on maternal factors. Odds of preterm and early-term birth were calculated. Results Sixteen thousand three hundred twelve women were identified as having an STI during pregnancy and an exact propensity score-matched control was identified for 97.2% (n = 15,860). Women with an indication of syphilis during pregnancy were at 1.6 times higher odds of having a preterm birth and, in particular, at elevated odds of a birth less than 32 weeks due to preterm premature rupture of the membranes or provider-initiated birth (odds ratios 4.0-4.2). Women with gonorrhea were at increased odds of a preterm birth, a birth less than 32 weeks, or an early-term birth (odds ratios 1.2-1.8). Chlamydia did not raise the odds of either a preterm or early-term birth. Conclusions Gonorrhea and syphilis increased the odds of a preterm birth. Gonorrhea also increased the odds of an early-term birth. Chlamydia did not raise the odds of an early birth.

Abstract

Preterm birth ( < 37 weeks gestation) continues to be a significant cause of disease and death in the United States. Its complex causes are associated with several genetic, biological, environmental, and sociodemographic factors. Organizing and visualizing various data that may be related to preterm birth is an essential step for pattern exploration and hypothesis generation and presents an opportunity to increase public and stakeholder involvement. In this article, we describe a collaborative effort to create an online geographic data visualization tool using open software to explore preterm birth in Fresno County, where rates are the highest in California. The tool incorporates information on births, environmental exposures, sociodemographic characteristics, the built environment, and access to care. We describe data sets used to build the tool, the data-hosting platform, and the process used to engage stakeholders in its creation. We highlight an important example of how collaboration can increase the utility of geographic data visualization to improve public health and address health equity in birth outcomes.

Abstract

Few investigations examine patterns of opioid and nonopioid analgesic prescribing and concurrent pain intensity ratings before and after institution of safer prescribing programs such as the October 2013 Veterans Health Administration system-wide Opioid Safety Initiative (OSI) implementation. We conducted a quasi-experimental pre-post observational study of all older U.S. veterans (≥50 years old) with osteoarthritis of the knee or hip. All associated outpatient analgesic prescriptions and outpatient pain intensity ratings from January 1, 2012 to December 31, 2016, were analyzed with segmented regression of interrupted time series. Standardized monthly rates for each analgesic class (total, opioid, nonsteroidal anti-inflammatory drug, acetaminophen, and other study analgesics) were analyzed with segmented negative binomial regression models with overall slope, step, and slope change. Similarly, segmented linear regression was used to analyze pain intensity ratings and percentage of those reporting pain. All models were additionally adjusted for age, sex, and race. Before OSI implementation, total analgesic prescriptions showed a steady rise, abruptly decreasing to a flat trajectory after OSI implementation. This trend was primarily due to a decrease in opioid prescribing after OSI. Total prescribing after OSI implementation was partially compensated by continuing increased prescribing of other study analgesics as well as a significant rise in acetaminophen prescriptions (post-OSI). No changes in nonsteroidal anti-inflammatory drug prescribing were seen. A small rise in the percentage of those reporting pain but not mean pain intensity ratings continued over the study period with no changes associated with OSI. Changes in analgesic prescribing trends were not paralleled by changes in reported pain intensity for older veterans with osteoarthritis.

Abstract

Aims: To conduct a needs assessment of public hospitals in Mexico to determine workforce specific capacity building needs in the care of older people. Background: The older population in Mexico is growing rapidly. The healthcare system and workforce may not be prepared to handle the needs of older people, especially those with chronic illnesses who are also disadvantaged socioeconomically. Determining workforce and system needs is important to strategically develop capacity. Methods: A needs assessment using a pragmatic qualitative approach structured this study. Semi-structured interviews and focus groups were conducted with healthcare professionals at five public hospitals in Mexico. Directed content analysis techniques analysed the data. Results: Ninety-two healthcare professionals participated in the study. Three themes emerged, including geriatric service delivery, social changes and human resources for health. Participants reported a lack of gerontology knowledge and related clinical skills deficits to provide care for hospitalised elders and expressed emotional distress related to the lack of resources in their institutions. All healthcare professionals expressed strong concern at the social toll the ageing population had on families. The support of government organisations emerged as a facilitator for adoption of geriatric care principles. Conclusions: This qualitative study uncovered important data to inform the implementation of quality improvement and capacity building models for older people care in Mexico. There appears to be strong potential for a culturally appropriate translation of high-income country older people care models within the Mexican healthcare context. Implications for practice: Findings suggests there is a need to increase geriatric capacity building among helathcare professionals in Mexico. This will be an important step in improving care for hospitalised older people.

Abstract

Background: The quality of the dying experience among older adults should improve with a better understanding of the dying experience and its association with the place of death in Mainland China. Objective: This study investigated the relationship between the dying experience and place of death among older Chinese adults in the context of an urban-rural bifurcated system. Design: We used the end-of-life module data from the China Longitudinal Aging Social Survey conducted in 2014 and 2016 with an eligible sample of 352 decedents ages 60 and older. Facial expression and sadness at the end of life were indicators of the dying experience in the present study. We performed multiple regression models to examine the association between the place of death and dying experience after adjusting for an ecological array of factors at the individual, family, and community levels. Results: The urban-rural differences in the association between facial expression at death and place of death were identified (interaction term: β = 0.16, p = 0.004). Among the decedents with a rural residence status, dying in a hospital was associated with a more peaceful facial expression at death than dying at home (p < 0.001). Among the decedents with an urban residence status, the place of death was not significantly related to the dying experience. Conclusion: Although home is perceived as a common place for death, the findings revealed that dying at home was less positive for rural older adults compared with dying in hospital. Bridging the gaps between urban and rural areas is necessary for the reform and construction of health care and long-term care systems in China.

Abstract

Background: Poor adherence to prescribed antihypertensive medication is a major contributor to disparities in effective blood pressure control among Hispanics. The purpose of this study was to investigate the association between health literacy level and adherence to antihypertensive medications among Hispanic adults, who self-reported hypertension, controlling for potential covariates of adherence and/or health literacy. Methods: We conducted a cross-sectional survey of 1355 Hispanic adults, primarily Dominicans, who self-reported hypertension. Antihypertensive medication adherence and health literacy were evaluated along with covariates, including sociodemographic characteristics, depression, anxiety, and sleep disturbance. Linear regression models were created for health literacy, each covariate, and adherence. Factors found to be significantly associated with adherence in the individual regression models at a p value of < 0.20 were included in a hierarchical multiple linear regression model. Results: Overall, the majority of participants had low adherence levels to antihypertensive medications (88.4%; n = 1026) and inadequate health literacy (84.9%; n = 1151). When controlling for age, sex, birth country, education level, recruitment location, depression, anxiety, and sleep disturbance, having adequate as compared to inadequate health literacy was associated with a higher adherence score (b = 0.378, p = 0.043). The full model explained 13.6% of the variance in medication adherence (p value < 0.001), but the unique contribution of health literacy to the model was minimal (R2 change = 0.003). Conclusions: Tailored interventions considering health literacy are needed to support medication adherence in order to improve hypertension outcomes of Hispanics. Additional studies are needed to identify and prioritize factors in the development of targeted and effective adherence interventions for Hispanics with hypertension.

Abstract

BACKGROUND: The purpose of the study is to examine the association between tooth loss and hypertension among older community residents in urban China.METHODS: This study included 3677 participants aged ≥50 years from the Shanghai Aging Study. We determined the number of teeth missing from questionnaires. Hypertension was defined as the mean of two measurements of systolic blood pressure (SBP) (140 mmHg or higher), diastolic blood pressure (DBP) (90 mmHg or higher) or physician-diagnosed hypertension confirmed from medical records. A multivariable logistic regression model was used to investigate the association between tooth loss and hypertension.RESULTS: The average number of missing teeth among study participants was 9.67. Among them, participants with hypertension had lost an average of 10.88 teeth, significantly higher than those without hypertension (8.95) (p < 0.0001). After adjusting for covariates (socio-demographic characteristics, health behaviors and other chronic conditions), teeth lost (15 or more) was significantly associated with grade III hypertension, with OR = 1.55(95% CI 1.09-2.20).CONCLUSIONS: Significant tooth loss maybe associated with severe hypertension among older Chinese adults. Prevention of tooth loss is important to the overall health of this population.

Abstract

Study Objective: To evaluate the association between use of methadone, other central nervous system (CNS) depressants, and QTc interval–prolonging medications and risk of mortality among human immunodeficiency virus (HIV)-infected and at-risk HIV-uninfected women. Design: Multicenter, prospective, observational cohort study (Women's Interagency HIV Study [WIHS]). Participants: A total of 4150 women enrolled in the WIHS study between 1994 and 2014 who were infected (3119 women) or not infected (1031 women) with HIV. Measurements and Main Results: Data on medication utilization were collected from all study participants via interviewer-administered surveys at 6-month intervals (1994–2014). Mortality was confirmed by National Death Index data. With age defining the time scale for the analysis, Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause mortality in HIV-infected and -uninfected women and non–acquired immunodeficiency syndrome (AIDS) deaths in HIV-infected women. A total of 1046 deaths were identified, of which 429 were considered non-AIDS deaths. Use of benzodiazepines, CNS depressants (excluding methadone), and number of medications with conditional QTc interval–prolonging effects were each associated with all-cause mortality in multivariate models of HIV-infected women: hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.01–1.60, p=0.037; HR 1.61, 95% CI 1.35–1.92, p<0.0001; and HR 1.15 per drug, 95% CI 1.00–1.33, p=0.047, respectively. Other explanatory variables for all-cause mortality in this model included HIV viral load, CD4+ cell count, renal function, hemoglobin and albumin levels, HIV treatment era, employment status, existence of depressive symptoms, ever use of injection drugs, and tobacco smoking. Of interest, use of CNS depressants (excluding methadone) was also associated with non-AIDS deaths (HR 1.49, 95% CI 1.49–2.2, p<0.0001). Although use of benzodiazepines and conditional QT interval–prolonging medications were associated with increased risk of non-AIDS mortality (HR 1.32 and 1.25, respectively), the effect was not statistically significant (p>0.05). Conclusion: In this cohort of HIV-infected and at-risk HIV-uninfected women, use of benzodiazepines, CNS depressants, and conditional QTc interval–prolonging medications were associated with a higher risk of mortality independent of methadone and other well-recognized mortality risk factors. Care must be taken to assess risk when prescribing these medications in this underserved and at-risk patient population.

Abstract

Importance: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves more than one-quarter of pregnant and postpartum women. In October 2009, the WIC food package underwent revisions to improve nutritional content. No studies have investigated the downstream effects of this revision on maternal and infant health. Objective: To investigate whether the revised WIC food package improved perinatal and birth outcomes among recipients. Design, Setting, and Participants: We conducted a quasi-experimental difference-in-differences analysis, comparing WIC recipients (the treatment group) before and after the package revisions while accounting for temporal trends among nonrecipients (the control group). Multivariable linear regressions were adjusted for sociodemographic covariates. This study was conducted using linked birth certificate and hospital discharge data from California from January 2007 to December 2012. Analysis began July 2018. Exposures: Whether pregnant women received the revised WIC package, which included more whole grains, fruit, vegetables, and low-fat milk. Main Outcomes and Measures: Measures of maternal and infant health, including maternal preeclampsia, gestational diabetes, and gestational weight gain as well as infant gestational age, birth weight, and hospitalizations. Results: The sample included 2897537 infants born to 2441658 mothers. WIC recipients were more likely to be Hispanic, less educated, of greater parity, and younger than nonrecipients. The revised WIC food package was associated with reductions in maternal preeclampsia (-0.6% points; 95% CI, -0.8 to -0.4) and more than recommended gestational weight gain (-3.2% points; 95% CI, -3.6 to -2.7), increased likelihood of as recommended (2.3% points; 95% CI, 1.8 to 2.8) and less than recommended (0.9% points; 95% CI, 0.5 to 1.2) gestational weight gain, and longer gestational age (0.2 weeks; 95% CI, 0.001 to 0.034). Among infants, an increased likelihood of birth weight that was appropriate for gestational age was observed (0.9% points; 95% CI, 0.5 to 1.3). Although birth weight itself was reduced (-0.009 SDs; 95% CI, -0.016 to -0.001), this was accompanied by reductions in small for gestational age (-0.4% points; 95% CI, -0.7 to -0.1), large for gestational age (-0.5% points; 95% CI, -0.8 to -0.2), and low-birth-weight infants (-0.2% points; 95% CI, -0.4 to -0.004), suggesting that the revised food package improved distributions of birth weight. Conclusions and Relevance: The revised WIC food package, intended to improve women's nutrition during pregnancy, was associated with beneficial impacts on maternal and child health. This suggests that WIC policy may be an important lever to reduce health disparities among high-risk women and children at a critical juncture in the life course.