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BACKGROUND: Retaining participants in multi-year prospective cohort studies presents challenges, especially in urban settings. Early identification of participants at risk for attrition may enhance retention. We examine the validity of two risk for loss-to-follow-up assessments and early retention efforts in one Primary Sampling Unit during the National Children’s Study pilot. Our goal was to identify cases requiring additional attention. Retention challenges included high poverty, frequent moves, lack of spousal support, and mistrust of research. METHODS: Recruitment ended in 2012 and research activities shifted to retention. Data collectors (DC) completed subjective risk assignments (low, medium, high) based on knowledge of participants. Descriptive statistics compared risk assessments to socio-demographic characteristics, responses regarding participation, and missed appointments 11 months after risk assessment. RESULTS: We recruited approximately 100 participants. Higher perceived risk was associated with greater likelihood for mothers to be minorities, younger, and have lower education and income (X2=15.362, p<.01; X2=12.118, p<.05; X2=9.947. p<.01; and X2= 7.720, p<.05 respectively). Participants with income below federal poverty placed higher values on receiving incentives (X2= 6.011 p<.05). African American or “other” race participants placed a higher value on feeling comfortable with the interviewers than White respondents (X2=12.539 p<.01). Risk assignment and race were associated with number of missed appointments (X2=8.698 p<.01; X2 =4.307, p<.05). CONCLUSION: Results suggest DCs’ subjective assessment of risk predicts number of missed appointments. Future research might consider strategies to improve African American and “other” race participants’ comfort with interviewers. The ethics of dollar amounts for incentives among low-income participants remain a concern.

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Local Health Departments (LHDs) are administrative unit of a local or state government, concerned with the health of a community or county. There are approximately 2,800 agencies or units that meet the profile definition of LHD. These LHDs vary in size and composition depending on the population they serve. However, all these communitybased agencies share a common mission of “protecting and improving community wellbeing by preventing disease, illness, and injury while impacting social, economic, and environmental factors fundamental to excellent health”. One of the ongoing challenge of a focus on community-level, population-based prevention is the manner in which local public health agencies have been funded. Most LHDs funding comes from federal funds, supplemented by state and local funds. Many of these funds come to LHDs through competitive grants programs. This study was therefore undertaken to investigate the sources of funding for the Local Public Health Agencies, according to geography specifically rurality. We utilized the data already compiled by the National Association of County & City Health Officials (NACCHO) in 2013. The population served by these health agencies were compared to the funding sources, and one –way ANOVA to estimate the significance between these variables. Our dependent variables were assigned to be the funding sources, while the independent variables were the two population categories –rural and urban. A categorical variable reflecting three levels of rurality was constructed using RUCA codes. “Urban” included census tracts with towns with populations >50,000. “Large rural” included census tracts with towns of between 10,000 and 49,999 population and census tracts tied to these towns through commuting. “Small rural” included census tracts with small towns of fewer than 10,000 population, tracts tied to small towns, and isolated census tracts. Furthermore, we also determined the proportion of revenue from these funding sources received by these three population groups. All analyses were completed using SPSS. There were no differences in the amount of revenues received by both the large and small rural and urban agencies from the State & Federal sources (p value = 0.182). However, urban agencies receive more funding from Medicare and Medicaid services (19.9%) compared to small rural with 6.9% (p<0.001). Comparatively, the amount of revenue generated by rural agencies is just a fraction of what the urban agencies generate. Residents of rural areas in the United States tend to be older and poorer, report more risky health behaviors, have more barriers to accessing health care, and have worse health status and health outcomes than do their urban counterparts. These rural LHDs have fewer resources and face strenuous challenges in carrying out their activities of keeping the community safe due to limited revenues. Until public health agencies are firmly connected to payment and funding mechanisms across the health system, communities, the overall health system and accountable care organizations will not see the true benefits of population-focused, community-based, prevention services.

Background: Engagement in the core public health functions and ten essential services remains the standard for measuring local health department (LHD) performance; their role as providers of clinical services remains uncertain, particularly in rural and underserved communities. Purpose: To examine the role of LHDs as clinical service providers and how this role varies among rural and nonrural communities. Methods: The 2013 National Association of County and City Health Officials (NACCHO) Profile was used to examine the geographic distribution of clinical service provision among LHDs. LHDs were coded as urban, large rural, or small rural based on Rural/Urban Commuting Area codes. Bivariate analysis for clinical services was conducted by rural/urban status. For each service, the proportions of LHDs that directly performed the service, contracted with other organizations to provide the service, or reported provision of the service by independent organizations in the community was compared. Results: Analyses show significant differences in patterns of clinical services offered, contracted, or provided by others, based on rurality. LHDs serving rural communities, especially large rural LHDs, tend to provide more direct services than urban LHDs. Among rural LHDs, larger rural LHDs provided a broader array of services and reported more community capacity for delivery than small rural LHDs- particularly maternal and child health services. Implications: There are capacity differences between large and small rural LHDs. Limited capacity within small rural LHDs may result in providing less services, regardless of the availability of other providers within their communities. These findings provide valuable information on clinical service provision among LHDs, particularly in rural and underserved communities.

Breastfeeding has health benefits for mother and child, allowing a mother to protect her newborn from numerous infections while promoting healthy nutrition and growth. Breastfed babies have decreased risk of later negative health problems including respiratory infection, asthma, obesity, and Type II diabetes. The minimum acceptable time a mother should breastfeed is six weeks, but major healthcare organizations, such as the American Academy of Pediatrics, recommend exclusive breastfeeding for the first six months of life. Nationally, 43.1% of babies were exclusively breastfed the first six weeks in 2009, and rates in rural Appalachia are known to be significantly lower than national averages. Researchers have found factors such as age, socioeconomic, marital, and smoking statuses to be predictive of breastfeeding continuation, but maternal innate characteristics have not been explored extensively. To clarify why a mother chooses to breastfeed or not, it is important to additionally look at intrinsic characteristics such as temperament. Temperament is an individual’s biologically based ability to think, behave, and react. Effortful control, a specific component of temperament, is the voluntary regulation of emotions and behaviors. The current study examined the impact of effortful control on participants’ likelihood of breastfeeding at six weeks postpartum. Informationwas collected from pregnant women recruited from Northeast Tennessee as part of the Tennessee Intervention for Pregnant Smokers Program. As part of the larger study, women completed detailed research interviews multiple times during pregnancy, and at six weeks post-partum. The responses of interest came from 230 women who had complete demographic questionnaire, Adult Temperament Questionnaire (ATQ), delivery and birth chart information, and six-week interview breastfeeding status. Logistic regression was used to assess the impact of maternal effortful control (subscale of the ATQ) on the mother’s decision to exclusively breastfeed the child up to six weeks postpartum. The model contained five variables that were significantly correlated with the breastfeeding continuation: maternal age, birth weight (normal/low), prematurity (yes/no), delivery type (vaginal/C-section), and maternal effortful control scores. The full model containing all predictors was statistically significant, X2 (5, N=230) =24.610, p < .001. Effortful control had an Exp(B) of .420, CI (.264, .668) p<.001. Those women who are still breastfeeding at six weeks have significantly higher self-reported effortful control than those who are not still breastfeeding at six weeks, controlling for several other known correlates of breastfeeding continuation. Effortful control was found to predict decreased breastfeeding at six weeks. Because effortful control is an aspect of temperament, and is therefore relatively fixed, its measurement may be useful for identifying women who are less likely to breastfeed so they can be targeted by health educators and clinicians for more intensive intervention. Any increase in breastfeeding holds the potential for positive health outcomes for both mother and child.