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Little research has explored relationships between prenatal substance use policies and rates of maternal mortality across all 50 states, despite evidence that prenatal substance use elevates risk of maternal death. This study, utilizing publicly available data, revealed that state-level mandated testing laws predicted maternal mortality after controlling for population characteristics.

UNASSIGNED: The majority of states have legalized medical cannabis. Nurse leaders must be prepared for an increase in patients\' use of the drug across all care settings.
UNASSIGNED: To explore nurse leaders\' attitudes towards, knowledge of, and experiences with medical cannabis.
UNASSIGNED: : Descriptive qualitative study design.
UNASSIGNED: 28 nurse leaders-19 in four focus groups of 3-7 participants and another 9 in interviews.
UNASSIGNED: Semi-structured, one-on-one interviews and focus groups of nurse leaders about their attitudes towards and experiences with patients\' use of medical cannabis. Thematic analysis was used to identify themes and subthemes.
UNASSIGNED: Four major themes were identified: overwhelming support for legalized medical cannabis; importance of overcoming the stereotype of a gateway drug; problematic mismatch between federal and state cannabis policies; and nursing needs to be move involved.
UNASSIGNED: There was strong support for legalized medical cannabis to meet patients\' needs; yet, respondents reported little discussion about or education regarding medical cannabis among nurses. Inconsistent federal and state cannabis policies were viewed as especially problematic and in need of alignment.

Relatively few studies rigorously examine the factors associated with health systems strengthening and scaling of interventions at subnational government levels. We aim to examine how The Challenge Initiative (TCI) coaches subnational (state government) actors to scale proven family planning and adolescent and youth sexual and reproductive health approaches rapidly and sustainably through public health systems to respond to unmet need among the urban poor.
This mixed-methods comparative case study draws on 32 semistructured interviews with subnational government leaders and managers, nongovernmental organization leaders, and TCI Nigeria staff, triangulated with project records and government health management information system (HMIS) data. Adapting the Consolidated Framework for Implementation Research (CFIR), we contrast experience across 2 higher-performing states and 1 lower-performing state (identified through HMIS data and selected health systems strengthening criteria from 13 states) to identify modifiable factors linked with successful adoption and implementation of interventions and note lessons for supporting scale-up.
Informants reported that several TCI strategies overlapping with CFIR were critical to states\' successful adoption and sustainment of interventions, most prominently external champions\' contributions and strengthened state planning and coordination, especially in higher-performing states. Government stakeholders institutionalized new interventions through their annual operational plans. Higher-performing states incorporated mutually reinforcing interventions (including service delivery, demand generation, and advocacy). Although informants generally expressed confidence that newly introduced service delivery interventions would be sustained beyond donor support, they had concerns about government financing of demand-side social and behavior change work.
As political and managerial factors, even more than technical factors, were most linked with successful adoption and scale-up, these processes and systems should be assessed and prioritized from the start. Government leaders, TCI coaches, and other stakeholders can use these findings to shape similar initiatives to sustainably scale social service interventions.

Consumer perceptions of legal cannabis products may drive willingness to purchase from the illegal or legal market; however, little is known on this topic. The current study examined perceptions of legal products among Canadian cannabis consumers over a 3-year period following federal legalization of non-medical cannabis in 2018.
Data were analyzed from Canadian respondents in the International Cannabis Policy Study, a repeat cross-sectional survey conducted in 2019-2021. Respondents were 15,311 past 12-month cannabis consumers of legal age to purchase cannabis. Weighted logistic regression models examined the association between perceptions of legal cannabis and province of residence, and frequency of cannabis use over time.
In 2021, cannabis consumers perceived legal cannabis to be safer to buy (54.0%), more convenient to buy (47.8%), more expensive (47.2%), safer to use (46.8%) and higher quality (29.3%) than illegal cannabis. Except for safety of purchasing, consumers had more favourable perceptions of legal cannabis in 2021 than 2019 across all outcomes. For example, consumers had higher odds of perceiving legal cannabis as more convenient to buy in 2021 than 2019 (AOR = 3.09, 95%CI: 2.65,3.60). More frequent consumers had less favourable perceptions of legal cannabis than less frequent consumers.
Three years since legalization, Canadian cannabis consumers generally had increasingly favourable perceptions of legal vs. illegal products - except for price - with variation across the provinces and frequency of cannabis use. To achieve public health objectives of legalization, federal and provincial governments must ensure that legal cannabis products are preferred to illegal, without appealing to non-consumers.

Recommended best practice for resource allocation decisions by governments include a stepwise process guided by economic evidence. However, the use of economic evidence in preventive health decision-making, which often impacts on multiple sectors of government, is under-researched. This study aimed to explore the resource allocation decision-making processes for preventive health interventions in the New South Wales (NSW) Government in Australia, and specifically examined the barriers and facilitators to the use of economic evidence from the perspective of multiple government departments.
This mixed methods study was conducted using semi-structured interviews with NSW Treasury representatives (n = 4), a focus group of NSW Ministry of Health representatives (n = 9), and a quantitative questionnaire of all participants. The schedule for the interviews and focus group was based on resource allocation guidance documents from Australian government agencies. Deductive content analysis was undertaken, guided by the Multiple Streams Framework.
NSW Treasury participants believed that decision-making processes where economic efficiency was the key guiding principle was the ideal approach. However, the NSW Ministry of Health participants identified that for preventive health decision-making, economic evidence was not used to inform their own choices but was typically only used to convince other agencies of the merits of proposed initiatives when seeking approval. The key barriers to the use of economic evidence were the lack of capacity within the NSW Ministry of Health to understand and undertake economic evaluations; a lack of collaboration between NSW Treasury and preventive health decision-makers within the NSW Ministry of Health; and deficient processes and governance mechanisms that do not facilitate or incentivise effective inter-sectoral decision-making.
Institutional structures for resource allocation decision-making regarding preventive health result in processes that contrast with best practice recommendations. The multiple challenges to collaborative decision-making across agencies require organisational change to promote a whole-of-government approach.

Social determinants are receiving renewed attention as research demonstrates the effects of social factors on individuals\' physical and mental health and elucidates the biological and psychological mechanisms underlying those effects. Through spheres of influence from policy and regulation development to direct service provision, state mental health agencies are in a unique position to lead primary and secondary prevention efforts aimed at addressing social determinants with both client-level and structural-level interventions. A survey of social determinants-related activity was sent to the Medical Directors of the state offices of mental health in all 50 states. The survey results suggest consensus among respondents as to the importance of addressing specific social determinants. However, few state mental health agencies have taken on a comprehensive and intentional approach to addressing social determinants as a unique area of activity. Specific activities are reviewed, and implications for future work is discussed.

Return to employment is a major barrier to breastfeeding continuation, globally and in the Southern African context. The Lancet Breastfeeding Series revealed an explicit need for research exploring breastfeeding as a workplace issue in low- and middle-income countries. A dearth of research on workplace breastfeeding in South Africa calls for attention to this topic. This study sought to explore breastfeeding at work experiences from the perspective of employed mothers and senior managers in a provincial government setting in South Africa.
The study adopted an exploratory qualitative design with multi-perspective semi-structured interviews. Snowball sampling was employed to recruit twelve participants, senior managers (n = 4) and employed mothers (n = 8), from two provincial government departments in Cape Town, South Africa. Interviews were conducted between April and August 2018 to capture participants\' experiences with breastfeeding in the workplace. Thematic analysis was used to analyse data.
Four key themes that described experiences of workplace breastfeeding emerged which further traversed three critical maternity periods: pregnancy, maternity leave, and return to work. The prevalent themes were: 1) Knowledge about the legislation and breastfeeding support benefits. Most participants only knew about the legislated four months maternity leave and time off for prenatal visits but lacked knowledge about comprehensive maternity benefits; 2) Perceptions and experiences of breastfeeding in the workplace. Breastfeeding was perceived to be a mother\'s responsibility and a private issue. As a result, most participants stopped breastfeeding prior to or immediately upon return to work after maternity leave; 3) Barriers to breastfeeding continuation, such as the absence of a conversation about infant feeding plans between managers and mothers; and 4) Recommendations to improve breastfeeding support at work from an individual, organisational and national level.
Our study contributions emphasise that breastfeeding support from managers should begin prior to the mother taking maternity leave, and that in addition to providing supportive facilities (such as private space and breastmilk storage), immediate supervisor support may be critical in fostering breastfeeding-friendly workplaces for mothers. Management implications for advancing workplace breastfeeding support in the public sector are presented.

BACKGROUND: State regulations may impede the use of nurse-initiated protocols to begin life-saving treatments when patients arrive to the emergency department. In crowding and small-scale disaster events, this could translate to life and death practice differences. Nevertheless, research demonstrates nurses do utilize nurse-initiated protocols despite legal prohibitions. The purpose of this study was to explore the relationship of the state regulatory environment as expressed in nurse practice acts and interpretive statements prohibiting the use of nurse-initiated protocols with hospital use of nurse-initiated protocols in emergency departments.
METHODS: A cross-sectional approach was used with a nationwide survey. The independent variable categorized the location of the hospital in states that have a protocol prohibition. Outcomes included protocols for blood laboratory tests, X-rays, over-the-counter medication, and electrocardiograms. A second analysis was completed with New York State alone because this state has the strongest language prohibiting nurse-initiated protocols.
RESULTS: A total of 350 participants returned surveys from 48 states and the District of Columbia. A hospital was more likely to have policies supporting nurse-initiated protocols if they were not in a state with the scope of practice prohibitions. Four categories emerged such as advantages, approval, prohibition, and conditions under which the protocols can be used. Prohibitive language was associated with less protocol use for emergency care.
CONCLUSIONS: State scope of practice inconsistencies create misalignment with emergency nurse education and training, which may impede timely care and contribute to inequalities and inefficiencies in emergency care. In addition, prohibitive language places practicing nurses responding to emergencies in crowded work environments at risk.

To assess the relationship between the presence and generosity of state-level Earned Income Tax Credits (EITC) and multiple self-reported measures of general health.
Data on state-level tax credits and covariates were obtained from the National Bureau of Economic Research and University of Kentucky Center for Poverty Research, respectively. These data were merged with Behavioral Risk Factor Surveillance System survey records from 1993-2016.
Using difference-in-differences approaches and survey-weighted Poisson regression that accounted for clustering of observations and included state and year fixed-effects, we assessed relationships between EITC and self-reported overall health, frequent mental distress, and frequent poor physical health in the prior 30 days. Covariates included state minimum wage, state GDP, and adoption of Medicaid expansion. Sensitivity analyses revealed that parallel trends were plausible; there were no significant lead and lag effects.
Analyses were restricted to respondents with no more than a high school diploma or equivalent because less-educated adults are more likely to be low-wage earners and therefore qualify for EITC.
Among adults with no education beyond high school (n = 2 884 790), each additional 10-percentage-point increase in the generosity of state EITC-relative to the federal credit-was associated with fewer reports of frequent mental distress (-97.3 per 100 000; 95% CI: -237.2, 42.6) and frequent poor physical health (-149.6 per 100 000; 95% CI: -284.4, -14.9). When restricted to individuals interviewed during the three months when tax rebates are commonly disbursed, the magnitude of the association between EITC and prevalence of reported frequent mental distress was greater (-329.7 per 100 000; 95% CI: -636.0, -23.5).
The generosity of state EITC policies is positively associated with significant reductions in frequent mental distress and poor physical health, especially during months when the credit is received. Interventions to reduce poverty may positively impact health by reducing material hardship and stress.