OBJECTIVE: The purpose of this study was to characterize the relationship between maternal depressive symptoms and employment and whether it is mediated by social support. METHODS: We used data from a nationally representative sample of 700 US women who gave birth in 2005 and completed 2 surveys in the Listening to Mothers series, the first in early 2006, an average of 7.3 months postpartum, and the second an average of 13.4 months postpartum. A dichotomous measure of depressive symptoms was calculated from the 2-item Patient Health Questionnaire, and women reported their employment status and levels of social support from partners and others. We modeled the association between maternal employment and depressive symptoms using multivariate logistic regression, including social support and other control variables. RESULTS: Maternal employment and high support from a nonpartner source were both independently associated with significantly lower odds of depressive symptoms (adjusted odds ratio [AOR], 0.35 and P = .011, and AOR, 0.40, P = .011, respectively). These relationships remained significant after controlling for mothers' baseline mental and physical health, babies' health, and demographic characteristics (AOR, 0.326 and P = .015, and AOR, 0.267 and P = .025, respectively). CONCLUSIONS: Maternal employment and strong social support, particularly nonpartner support, were independently associated with fewer depressive symptoms. Clinicians should encourage mothers of young children who are at risk for depression to consider ways to optimize their employment circumstances and "other" social support.

This study examines the association of leave duration with depressive symptoms, mental health, physical health, and maternal symptoms in the first postpartum year, using a prospective cohort design. Eligible employed women, eighteen years or older, were interviewed in person at three Minnesota hospitals while hospitalized for childbirth in 2001. Telephone interviews were conducted at six weeks (N = 716), twelve weeks (N = 661), six months (N = 625), and twelve months (N = 575) after delivery. Depressive symptoms (Edinburgh Postnatal Depression Scale), mental and physical health (SF-12 Health Survey), and maternal childbirth-related symptoms were measured at each time period. Two-stage least squares analysis showed that the relationship between leave duration and postpartum depressive symptoms is U-shaped, with a minimum at six months. In the first postpartum year, an increase in leave duration is associated with a decrease in depressive symptoms until six months postpartum. Moreover, ordinary least squares analysis showed a marginally significant linear positive association between leave duration and physical health. Taking leave from work provides time for mothers to rest and recover from pregnancy and childbirth. Findings indicate that the current leave duration provided by the Family and Medical Leave Act, twelve weeks, may not be sufficient for mothers at risk for or experiencing postpartum depression.

INTRODUCTION In the 1990s, several organizations began recommending evaluation of > 12 lymph nodes during colon resection because of its association with improved survival. We examined practice implications of multispecialty quality guidelines over the past 20 years recommending evaluation of ≥ 12 lymph nodes during colon resection for adequate staging. MATERIALS AND METHODS We used the 1988 to 2009 Surveillance, Epidemiology, and End Results program to conduct a retrospective observational cohort study of 90,203 surgically treated patients with colon cancer. We used Cochran-Armitage tests to examine trends in lymph node examination over time and multivariate logistic regression to identify patient characteristics associated with guideline-recommended lymph node evaluation. RESULTS The introduction of practice guidelines was associated with gradual increases in guideline-recommended lymph node evaluation. From 1988 to 1990, 34% of patients had > 12 lymph nodes evaluated, increasing to 38% in 1994 to 1996 and to > 75% from 2006 to 2009. Younger, white patients and those with more-extensive bowel penetration (T3/4 nonmetastatic) and high tumor grade saw more-rapid increases in lymph node evaluation (P < .001). Multivariate analyses demonstrated a significant interaction between year of diagnosis and both T stage and grade, indicating that those with higher T stage and higher grade were more likely to receive guideline-recommended care earlier. CONCLUSION The implementation of lymph node evaluation guidelines was accepted gradually into practice but adopted more quickly among higher risk patients. By identifying patients who are least likely to receive guideline-recommended care, these findings present a starting point for promoting targeted improvements in cancer care and further understanding underlying contributors to these disparities.

BACKGROUND: Over the past 20 years, surgical practice organizations have recommended the identification of >/=12 lymph nodes from surgically treated colon cancer patients as an indicator of quality performance for adequate staging; however, studies suggest that significant variation exists among hospitals in their level of adherence to this recommendation. We examined hospital-level factors that were associated with institutional improvement or maintenance of adequate lymph node evaluation after the introduction of surgical quality guidelines. RESEARCH DESIGN: Using the 1996-2007 SEER-Medicare data, we evaluated hospital characteristics associated with short-term (1999-2001), medium-term (2002-2004), and long-term (2005-2007) guideline-recommended (>/=12) lymph node evaluation compared with initial evaluation levels (1996-1998) using chi tests and multivariate logistic regression analysis, adjusting for patient case-mix. RESULTS: We identified 228 hospitals that performed >/=6 colon cancer surgeries during each study period from 1996-2007. In the initial study period (1996-1998), 26.3% (n=60) of hospitals were performing guideline-recommended evaluation, which increased to 28.1% in 1999-2001, 44.7% in 2002-2004, and 70.6% in 2005-2007. In multivariate analyses, a hospital's prior guideline performance [odds ratio (OR) (95% confidence interval (CI)): 4.02 (1.92, 8.42)], teaching status [OR (95% CI): 2.33 (1.03, 5.28)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 3.39 (1.39, 8.31)] were significantly associated with short-term guideline-recommended lymph node evaluation. Prior hospital performance [OR (95% CI): 2.41 (1.17, 4.94)], urban location [OR (95% CI): 2.66 (1.12, 6.31)], and American College of Surgeon's Oncology Group membership [OR (95% CI): 6.05 (2.32, 15.77)] were associated with medium-term performance; however, these factors were not associated with long-term performance. CONCLUSIONS: Over the 12-year period, there were marked improvements in hospital performance for guideline-recommended lymph node evaluation. Understanding patterns in improvement over time contributes to debates over optimal designs of quality-improvement programs.

BACKGROUND: Postpartum employment is associated with non-initiation and early cessation of breastfeeding, but less is known about the relationship between prenatal employment and breastfeeding intentions and behaviors. OBJECTIVE: This study aimed to estimate the relationship between prenatal employment status, a strong predictor of postpartum return to work, and breastfeeding intentions and behaviors. METHODS: Using data from the Listening to Mothers II national survey (N = 1573), we used propensity score matching methods to account for non-random selection into employment patterns and to measure the impact of prenatal employment status on breastfeeding intentions and behaviors. We also examined whether hospital practices consistent with the Baby-Friendly Hospital Initiative (BFHI), assessed based on maternal perception, were differentially associated with breastfeeding by employment status. RESULTS: Women who were employed (vs unemployed) during pregnancy were older, were more educated, were less likely to have had a previous cesarean delivery, and had fewer children. After matching, these differences were eliminated. Although breastfeeding intention did not differ by employment, full-time employment (vs no employment) during pregnancy was associated with decreased odds of exclusive breastfeeding 1 week postpartum (adjusted odds ratio = 0.48; 95% confidence interval, 0.25-0.92; P = .028). Higher BFHI scores were associated with higher odds of breastfeeding at 1 week but did not differentially impact women by employment status. CONCLUSION: Women employed full-time during pregnancy were less likely to fulfill their intention to exclusively breastfeed, compared to women who were not employed during pregnancy. Clinicians should be aware that employment circumstances may impact women's breastfeeding decisions; this may help guide discussions during clinical encounters.

BACKGROUND Among surgically treated patients with colon cancer, lower long-term mortality has been demonstrated in those with 12 or more lymph nodes evaluated. We examined whether patients receiving adequate lymph node evaluation were also more likely to receive comprehensive postsurgical care, leading to lower mortality. STUDY DESIGN We used the 1992 to 2007 Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify surgically treated American Joint Committee on Cancer (AJCC) stage III colon cancer patients. We used chi-square analyses and logistic regression to evaluate the association between adequate (≥12) lymph node evaluation and receipt of postsurgical care (adjuvant chemotherapy, surveillance colonoscopy, CT scans, and CEA testing) and Cox proportional hazards regression to evaluate 10-year all-cause mortality, adjusting for postsurgical care. RESULTS Among 17,906 surgically treated stage III colon cancer patients, adequate (≥12) lymph node evaluation was not associated with receiving comprehensive postsurgical care after adjustment for patient and tumor characteristics (p > 0.05 for all). Initially, adequate lymph node evaluation was associated with lower all-cause mortality (hazard ratio [HR] 0.88; 95% CI [0.85 to 0.91]), but among 3-year survivors, the impact of adequate lymph node evaluation on lower mortality was diminished (HR 0.94; 95% CI [0.88 to 1.01]). However, receiving comprehensive postsurgical care was associated with continued lower mortality in 3-year survivors. CONCLUSIONS Adequate lymph node evaluation for colon cancer was associated with lower mortality among all patients. However, among 3-year survivors, the association between lymph node evaluation and lower hazard of death was no longer significant, while postsurgical care remained strongly associated with lower long-term mortality, indicating that postsurgical care may partially explain the relationship between lymph node evaluation and mortality.

OBJECTIVE: To investigate the association of postpartum depression with health services expenditures among employed women. METHODS: Women, aged 18 years and older, were recruited from three community hospitals in Minnesota while hospitalized for childbirth in 2001. Using Andersen's Behavioral Model, we regressed the natural log of the price-weighted sum of self-reported health services used from hospital discharge until 11 weeks postpartum on depression status at 5 weeks postpartum (Edinburgh Postnatal Depression Scale). RESULTS: Five percent of the women met the depression threshold. Two-stage least squares analyses showed that depressed women incurred 90% higher health services expenditures than nondepressed women. Older age, poverty, non-public assistance insurance status, and increased maternal symptoms also were associated with higher expenditures. CONCLUSIONS: Higher health expenditures among postpartum depressed women highlight the importance of addressing mental health issues in the workplace.

A community-academic partnership was formed in Minnesota's Red River Basin for a 1-year planning grant preceding a larger intervention to reduce pesticide exposure among children. Photovoice, developed by Dr. Caroline Wang, was used by mothers to document pathways to pesticide exposure for their children along with other health and safety concerns. An evaluation of the partnership was conducted for mothers, and for the research team of local stakeholders and academics. Surveys consisting of structured and open-ended questions elicited information on the perception of the process and short-term outcomes. Questions were created based on objectives of the Photovoice project, satisfaction, and principles of community-based participatory research (CBPR). A high percentage of study participants and researchers indicated that the objectives of the effort had been met, the principles of CBPR had been realized and they were satisfied with the benefits of participation. A need for more thorough planning was identified related to long-term dissemination of knowledge generated. The evaluation provides insight on the strengths and weaknesses of the project, demonstrates to team members and funders that formative and summative outcomes were met, and serves as a model for community-academic partnerships utilizing Photovoice as one CBPR method.

OBJECTIVES: To examine the association of women's postpartum health with total workload (TWL), work and personal factors in the year after childbirth. METHODS: Employed women from Minneapolis and St Paul, Minnesota, were recruited while hospitalized for childbirth. Longitudinal analyses, using fixed effects regression models, estimated the associations of TWL, job satisfaction and stress, social support, perceived control, breastfeeding and infant characteristics with women's health at 5 weeks, 11 weeks, 6 months, and 12 months postpartum. RESULTS: Increased TWL over time was associated with significantly poorer mental health and increased symptoms. CONCLUSIONS: High TWL--including reduced time for rest, recovery, and sleep--is a risk factor for women's mental health and symptoms 12 months after childbirth. Women's postpartum health was positively associated with social support, which may help to decrease the negative effects of excess work.

OBJECTIVE: Identify the magnitude and risk factors for occupational physical assault (PA) and nonphysical violence (NPV) against Minnesota educators. METHODS: Among 26,000 randomly selected licensed kindergarten to grade 12 educators, 6469 eligible educators reported whether they experienced PA or NPV during the prior year. Multiple logistic regression models were based on directed acyclic graphs. RESULTS: Respective PA and NPV annual rates per 100 educators were 8.3 and 38.4. Work changes resulted among PA (13% to 20%) and NPV (22%) victims. Risks increased for master's prepared or education specialists who worked in public alternative schools and special education. Risks decreased for those working for more than 20 years, part time, and in private schools. Physical assault risk decreased when teaching grades 3 to 12 (vs kindergarten to grade 2), but NPV risk increased. CONCLUSION: Targeted efforts on specific violence risk and protective factors are essential to improve educators' work environments.