Background: Every year in the United States approximately half a million youth with special health care needs (SHCN) turn 18. Little is known about how this population fares during the transition to adulthood. Purpose: To examine transitions to adulthood for young adults with SHCN. Methods: Using data from two national longitudinal surveys: the Panel Study of Income Dynamics and the Survey of Adult Transitions and Health, I built linear and logistic regression models to evaluate the relationship between having a history of SHCN during childhood and key transitional outcomes during young adulthood (e.g., mental health status, educational attainment, employment, financial independence and subjective indicators of adulthood). A second set of logistic models examined associations between hypothesized risk and protective factors during childhood (e.g. family financial burden, care in a medical home and access to adequate insurance) and physical health outcomes during young adulthood for youth with SHCN. Multivariate models were adjusted for key confounders. Results: The majority of youth with a history of SHCN were doing well during the transition to adulthood. That said, compared to young adults without a history of SHCN, young adults with a history of SHCN were in significantly worse mental health (adjusted OR of experiencing a non-specific psychological disorder 3.90, 95% CI 1.78-8.53) and had significantly lower odds of graduating from high school (adjusted OR 0.55, 95% CI 0.32-0.96), attending college (adjusted OR 0.61, 95% CI 0.38-0.96), and receiving financial assistance from their families (adjusted OR 0.56, 95% CI 0.38-0.83). Amongst young adults with a history of SHCN, family financial burden during childhood significantly decreased the odds of being in good physical health during the transition to adulthood. There was limited evidence that receipt of care in a medical home or access to adequate insurance during childhood increased the odds of being in good physical health for young adults with a history of SHCN. Conclusions: These findings have important policy implications for programs serving youth with SHCN. Specifically, mental health and educational services may need to be expanded and more emphasis placed on addressing the non-medical determinants of health, like family financial burden.

“We carry our histories in our bodies, how could we not?” – Nancy Krieger In the United States and abroad, socioeconomic status (income, education, and occupation) greatly impacts health outcomes for a given population. There is a strong and consistent socioeconomic gradient within health outcomes which has been documented as far back as in Ancient Egypt and China (Krieger, Willains, & Moss, 1997; Liberatos, Link, & Kelsey, 1988) The general trend shows that individuals with higher socioeconomic status generally enjoy lower rates of morbidity (disease) and disability, which can ultimately lead to higher mortality rates (House et al. (1992) and House et al. (1994); Williams & Collins, 1995). Most of the literature focuses on the impact of race or gender on socioeconomic status and therefore health status, but rarely is the intersectionality of both race and gender—a factor in the lives of all Afro-American women—the focus of this inquiry. This research views socioeconomic factors in light of historical and sociological conditions which shape present urban environments in which Black women lives and grow. The goal of this thesis is to analyze the ways in which socioeconomic (particularly educational attainment) inequities lead to decreased health status of Afro-American women living in urban slums who fail to graduate high school. This research investigates the long-term effects of a) residential and educational segregation (b) racism and sexism within the educational system (c) racism and sexism within the healthcare system and (d) implications for morbidity and mortality rates amongst Afro-American women with respect to differences in educational attainment and high school dropout status. More research on this topic is necessary to better understand the direct correlation between educational attainment and health status among minority groups in the United States.

Background: Cigarette smoking is a leading preventable factor associated with complications in pregnancy including preterm birth and low birthweight. Past interventions have raised cessation rates by approximately 6% overall (Lumley et al. 2009). Methods: A three-part literature review, two qualitative studies with a total of 36 participants, and the development of an intervention to promote smoking cessation during pregnancy were completed. Central to the design of the research was the creation of the theoretical basis which was developed in line with recommendations from the MRC Framework for Complex Interventions (Craig et al. 2008, Campbell et al. 2000). For part one of the literature review, 24 qualitative and 44 quantitative studies were re-analysed to complete a mixed-methods secondary analysis of the active ingredients in interventions to promote smoking cessation during pregnancy. Part two consisted of an exploration of psychological models and constructs which are likely to predict or influence smoking behaviour during pregnancy. The final part was a discussion regarding the modes of delivery by which an intervention could feasibly be delivered. Qualitative interviews were carried out with participants from stakeholder groups to fill in gaps in literature and determine the acceptability and feasibility of the proposed intervention. The intervention was created using the theoretical basis developed from the findings. Further qualitative interviews, a focus group, and heuristic evaluation were used to determine the acceptability and usability of the intervention for the target group of pregnant smokers. Results and Conclusions: Findings from this work are potentially relevant for a wide range of behaviours and behavioural interventions. An intervention which has a strong grounding in theory and evidence, and is acceptable and feasible for the target group and in clinical practice was developed using evidence gathered in this thesis.

Context: Literature suggests that prenatal care and prenatal supplement use improves pregnancy outcomes. However, we do not know the factors associated with prenatal care and supplement use in Honduras.Objective: To identify characteristics of Honduran women who are the least and most likely to use prenatal care and supplements.Methods: Data from a 2001 Honduras cross-sectional survey of women was used to assess their use of prenatal care and supplements. All data was weighted, resulting in a sample size of n = 5647 women who had a live birth since January 1996. Bivariate and multivariate analyses were used to examine factors associated with prenatal care and supplement use.Results: Current education level was highly positively related to prenatal care and supplement use. Women who were 35 years or older at the time of their most recent birth, currently unmarried, of non-Catholic religious affiliation, and of low SES were significantly less likely to have used prenatal care and supplements. Women who reported the intentionality of their most recent birth as unwanted also were significantly less likely to have used prenatal care and supplements. Prenatal care was the most significant determinant of prenatal supplement use.Conclusion: There are significant differences between Honduran women who use prenatal care and supplements and women who do not. Efforts to increase prenatal health services among underserved women, especially women who are older, unmarried, with no formal education, of low SES, of a non-Catholic religious affiliation, and at risk for an unwanted pregnancy, may significantly improve pregnancy outcomes in Honduras.

Achieving efficiency, or maximizing the outputs achieved per unit of resource invested, is of great interest to governments, donors and other stakeholders in the health sector. Many studies consider efficiency in public health using Cost Effectiveness Analyses which estimate the health outcomes achieved per unit of cost. Others employ Technical Efficiency Analysis to understand which health system units, usually hospitals, provide the most health services per unit of resource. However, very little is known about demand-side efficiency or how efficiently individuals convert available health resources into health outcomes. To address this gap, I developed and piloted a two-stage methodology using Amartya Sen's Capability Approach as a theoretical framework mapping the process by which individuals convert resources into outcomes. The first stage estimates conversion efficiency using Order-m Efficiency Analysis then identifies the social groups most likely to be efficient using regression analysis. The second stage undertakes focus group discussions and semi-structured interviews to investigate how and why the social groups identified in the quantitative stage were more likely to be efficient. I conducted my analysis in Ba Vi district, northern Vietnam looking specifically at how efficiently pregnant women converted maternal health resources—including health facilities and human resources for health—into both appropriate care and healthy pregnancy and delivery. I found that ethnic minorities and women in non-mountainous areas were more likely to be efficient at achieving appropriate care while ethnic minorities and less educated women are more likely to be efficient at achieving healthy pregnancy and delivery outcomes. Through qualitative feedback, women who were ethnic majorities, better educated and generally more affluent expressed stronger technology preference, greater use of the private sector, less continuity of care, tendencies towards overnutrition, less focus on mental and emotional health and more varied sources of health information including advertising and the internet. Evidence links each of these themes to adverse care and/or health outcomes. Consequently, the more affluent populations, who also have a greater endowment of public health resources, may be less likely to achieve good outcomes—explaining at least in part why they are found to be less efficient. My findings highlight that the development process and attendant epidemiological and nutrition transitions give rise to a new set of challenges not solely for public health, but also for the efficiency with which it is achieved using existing health system resources.

As ações de saúde nos três níveis de atenção favorecem a melhoria da qualidade da assistência materno-infantil e, consequentemente, a detecção precoce de doenças e a redução de óbitos, e sabe-se que se as mesmas não forem implementadas e se não estiverem devidamente articuladas poderão desencadear danos a essa população. Dentro deste cenário, o presente estudo teve por objetivo principal caracterizar a atenção à saúde ao Bebê de alto risco, buscando mapear o fluxo dos cuidados em saúde na Rede para essa população e demonstrando os aspectos positivos e negativos do cuidado em saúde. Para que os objetivos fossem alcançados, foram selecionados aleatoriamente 22 bebês de Alto Risco, por meio de busca ativa nas Declarações de Nascidos Vivos da Supervisão Técnica de Saúde da região estudada. Após, foram agendadas reuniões com as Equipes de saúde de família de referência destes sujeitos para que o questionário baseado no PCA-Tool fosse aplicado. Posteriormente, as famílias foram contatadas para que também fosse aplicado tal instrumento. As potencialidades e as fragilidades da Rede de Cuidado ao Bebê de Alto Risco foram discutidas tanto no âmbito profissional quanto no âmbito familiar. Os dados foram analisados por meio de análise quantitativa. A mesma foi direcionada às comparações entre a percepção do grupo usuários e do grupo profissionais. Nos resultados deste estudo pode-se observar algumas variáveis que tiveram significância estatística, especialmente o vínculo com a UBS, o conhecimento dos indivíduos sobre a equipe NASF, a ciência das Equipes de Saúde da Família quanto ao diagnóstico de gravidez de risco e adesão ao pré natal, via de comunicação do nascimento dos indivíduos, a ciência quanto a necessidade de internação hospitalar, bem como sua duração, além do conhecimento sobre acompanhamento na ASS e o desfecho do mesmo, apontando para uma dificuldade no eixo da coordenação e longitudinalidade dos serviços prestados na Rede de cuidados do bebê de alto risco na região oeste do município de São Paulo / Health actions at the three levels of care favor the quality improvement of maternal and child care and, consequently, the early detection of diseases and the cutback on deaths. It is known that if they are not implemented and if they are not properly articulated, this population can be harmed. Within this scenario, the main objective of this study was to characterize health care for the high-risk infant, seeking to map the flow of health care in the public network for this population by demonstrating the positive and negative aspects of health care. In order to achieve the objectives, twenty-two high-risk infants were randomly selected through an active search in the Declarations of Live Births of the Health Technical Supervision of the studied region. Afterwards, meetings were scheduled with the reference family health teams of these subjects for the PCA-Tool-based questionnaire to be applied. Later on, the families were contacted for such instrument to be applied. The potentialities and weaknesses of the High-Risk Infant Care Network were discussed in both the professional and family contexts. Data were analyzed by means of quantitative analysis. The same was directed to the comparisons between the perception of the group users and the professional group. In the results of this study, some variables that had statistical significance are noteworthy, especially regarding the link to the UBS, the individuals\' knowledge about the NASF team, the Science of the Family Health Teams regarding the diagnosis of the high-risk pregnancy and adherence to the prenatal, communication path of the birth of the individuals, the awareness regarding the need for hospitalization, as well as its duration, in addition to the knowledge about the follow-up in the SSA and its outcome, pointing to a difficulty in the coordination axis and long service quality provided in the high-risk infant care network in the western region of the municipality of São Paulo

Objective: In 2010, the National Children’s Study launched 3 alternative recruitment methods to test possible improvements in efficiency compared with traditional household-based recruitment and participant enrollment. In 2012, a fourth method, provider-based sampling (PBS), tested a probability-based sampling of prenatal provider locations supplemented by a second cohort of neonates born at a convenience sample of maternity hospitals. Methods: From a sampling frame of 472 prenatal care provider locations and 59 maternity hospitals, 49 provider and 7 hospital locations within or just outside 3 counties participated in study recruitment. During first prenatal care visits or immediately postdelivery at these locations, face-to-face contact was used to screen and recruit eligible women. Results: Of 1450 screened women, 1270 were eligible. Consent rates at prenatal provider locations (62%–74% by county) were similar to those at birth locations (64%–77% by county). During 6 field months, 3 study centers enrolled a total prenatal cohort of 530 women (the majority in the first trimester) and during 2 months enrolled a birth cohort of an additional 320 mother-newborn dyads. As personnel became experienced in the field, the time required to enroll a woman in the prenatal cohort declined from up to 200 hours to 50 to 100 hours per woman recruited. Conclusions: We demonstrated that PBS was feasible and operationally efficient in recruiting a representative cohort of newborns from 3 diverse US counties. Our findings suggest that PBS is a practical approach to recruit large pregnancy and birth cohorts across the United States.

Objective: The Affordable Care Act (ACA) has influenced increasing interests in population health and population health outcomes. The purpose of this study was to exemplify the importance of using existing vital statistics data for understanding and monitoring health outcomes and consequentially health disparities at the population level. Data from birth records for two geographic regions from 2009-2014 were compared; low birth weight (LBW) and preterm delivery (PD) were used as surrogates for population health outcomes. Methods: A population-based, multi-year, cross-sectional study design using a pooled dataset of birth records from Tennessee (TN) was the framework for the analyses. A sub-population from North East TN (NE TN) was compared to TN. Logistic regression was used to estimate odds ratios. Attributable risks were calculated to translate the findings from conditional associations to population-level associations to help inform public health policy decision-making. Results: Using birth records (vital statistics), we demonstrated that the period prevalence of cigarette smoking before and during pregnancy remained unchanged with approximately one in three women in NE TN (from 37% in 2009 to 32% in 2014) and one in five women in TN (from 23% in 2009 to 20% in 2014) reporting smoking pre-pregnancy. Multivariate analyses demonstrated that mothers who were at each end of the age spectrum, of very low household income level and reported cigarette smoking pre-pregnancy or during pregnancy had increased risk of a LBW or PD infant. During the years of observation, 39 to 50% of the total incidence of LBW in the group of women who smoked cigarettes prior to pregnancy was attributable to smoking cigarettes. Conclusions: Existing data, such as vital statistics data, should be used routinely to identify geographic areas for which programs or policies can be implemented to reach large portions of populations. Reducing prenatal smoking, for example, has the potential to reduce a large fraction of adverse birth outcomes such as LBW and PD. For the geographic area we evaluated, 39 to 50% of LBW could be prevented by devising population-based smoking cessation programs or policies for women of child-bearing age. With recent emphasis on prevention and well-baby care in the ACA, there is potential to increase attention to this problem, implement evidence-based prevention programs and monitor program effectiveness with existing birth record data. Following this model, we can attain population health goals and address health disparities.

This quasi-experimental study compared family formation and perceived partner support among pregnant adolescents in a prenatal care program. Participants were assigned to either an intervention group utilizing centering pregnancy (CP) prenatal care and case management, or to a comparison group receiving case management only. Partners were invited to participate in CP group sessions. This study included 173 predominantly minority pregnant adolescents ages 15–18 years who were enrolled in a prenatal program and followed one month postpartum. Family formation included living and relationship arrangements. Perceived partner support included six domains of perceived social provisions. Data were collected through participants’ self-reports using computer-assisted self-interviews. Changes in family formation and perceptions of partner support from baseline to postpartum did not differ between intervention and comparison groups. Male partners who attended at least one CP session were perceived as more supportive at both the beginning and end of the program than partners who did not attend any sessions. After combining groups, pregnant adolescents reported a significant shift in family formation and increased monetary support from partners from baseline to postpartum. Partner support is important for ensuring positive pregnancy outcomes. Additional strategies are needed to engage young fathers who do not readily provide support during pregnancy.

Objetivos: Verificar os efeitos do acompanhamento fonoaudiológico no desenvolvimento das habilidades de alimentação do bebê no primeiro ano de vida. Métodos: Estudo de coorte prospectivo realizado entre abril de 2010 a maio de 2011, com binômios mãe/bebê inicialmente em uma maternidade na zona sul do município de São Paulo e acompanhados durante 12 meses. O grupo estudo foi constituído de RNs com 24 a 48 horas de vida, filhos de mães primigestas e maiores de 18 anos de idade, com escore 11 de acordo com o Escala de Avaliação Motora-Oral em Berçário, submetidos a acompanhamento fonoaudiológico. O grupo controle foi obtido de bebês nascidos na mesma maternidade, com APGAR 9 e > 2.500g., de mães com mesmas características, contatadas aos 12 meses. Resultados: A prevalência de desmame foi semelhante em ambos os grupos, entretanto o aleitamento materno apresentou Md de 7m e 5m nos grupos estudo e controle respectivamente (p=0,04). A introdução da consistência alimentar sólida foi em média 7,8m e 9,6m (p<0,01). Os copos de transição foram utilizados por 92,9% e 70,2% (p=0,01) e canudos por 59,5% e 27,7% (p=0,003). A prevalência do uso de chupeta foi 54,0% e 27,7% (p=0,01) aos 12 meses. Conclusões: O grupo acompanhado mostrou melhora no desempenho do aleitamento materno aos 2 meses. Comparado ao grupo controle, apresentou desmame mais tardio; redução do tempo de introdução da consistência sólida, mais utilização dos utensílios e menor prevalência do uso de chupeta aos 12m / Objectives: Investigate the effects of speech therapy in the development of feeding skills of the baby in the first year of life Methods: A prospective cohort study between April 2010 and May 2011 whit mother / baby binomial in a maternity hospital in the southern area of São Paulo and followed during 12 months. The study group consisted of newborns with 24 to 48 hours of life, children of primigravid mothers older than 18 years of age, wich had a score 11 according to the Oral-Motor in Nursery Assessment Scale undergoing speech therapy. The control group was obtained from babies born at the same hospital, with Apgar 9 and > 2,500 g, from mothers with similar characteristics who were contacted at 12 months. Results: The prevalence of weaning was similar in both groups, however breastfeeding presented Md of 7m and 5m in the study and control groups respectively (p = 0.04). The introduction of solid consistency food was at 7.8 m and 9.6 m (p <0.01). The glass transition were used by 92.9% and 70.2% (p = 0.01) and straws by 59.5% and 27.7% (p = 0.003). The prevalence of pacifier use was 54.0% and 27.7% (p = 0.01) at 12 months. Conclusions: The study group, compared to the control, presented: improvement in the performance of breastfeeding at 2 months, later weaning, reducing time for introduction of solid consistency food, wider use of utensils and lower prevalence of pacifier use at 12m