Assessing and Providing Marijuana Education to WIC Clients Following Legalization of Recreational Marijuana in Colorado

State: CO Type: Model Practice Year: 2016

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With the legalization of recreational marijuana in Colorado in January 2014, Tri-County Health Department in metro Denver wanted to understand marijuana use among women during and after pregnancy. There is a paucity of data on marijuana use during pregnancy, and the impact of legalization on adult marijuana use in the states currently permitting recreational use is also unknown. To enhance knowledge on this issue, we assessed marijuana use and educational needs among WIC clients in order to tailor public health messaging on the maternal and pediatric health effects of marijuana exposure during pregnancy and breastfeeding.

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Tri-County Health Department
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Assessing and Providing Marijuana Education to WIC Clients Following Legalization of Recreational Marijuana in Colorado
Tri-County Health Department Description: Tri-County Health Department (TCHD), Colorado’s largest local health department, is located in the Denver metro area serving Adams, Arapahoe and Douglas counties and 1.4 million residents. Nearly one-quarter of TCHD’s residents are of Hispanic ethnicity (23%). Almost two-thirds (64%) are white, Non-Hispanic, five percent are black/African American, five percent identify as Asian American/Pacific Islander or American Indian/Alaska Native. The remaining three percent identify as another race or two or more races. Public Health Issue: On January 1, 2014, Colorado became the first state in the nation to legalize recreational marijuana for adults over 21.  While products are regulated, there are public health concerns surrounding possible increased intentional use or unintentional exposure, especially among vulnerable populations such as children and adolescents and pregnant and breastfeeding women. The Colorado Department of Public Health and Environment (CDPHE) completed a report, Monitoring Health Concerns Related to Marijuana in Colorado: 2014. Changes in Marijuana Use Patterns, Systematic Literature Review, and Possible Marijuana-Related Health Effects in 2015.  Among key findings were moderate evidence that marijuana use in pregnancy is associated with decreased growth, academic ability, cognitive function, and attention in exposed offspring and moderate evidence that more unintentional exposure of children occurs in states with legal access.  The report also recommended more standardized data collection and survey tools to better characterize use patterns. The American College of Obstetrics and Gynecologists conducted a literature review and estimated that between two and five percent of women use marijuana during pregnancy. However, these data were collected prior to the legalization of recreational marijuana. It is unknown if the recent legislation in Colorado will encourage more people to use marijuana, including women who are pregnant or breastfeeding or have young children at home. The TCHD Special Supplemental Nutrition Program for Women, Infants and Children (WIC) has a monthly average caseload of 24,324 clients. TCHD staff felt that the recent legalization of recreational marijuana was an opportune time to conduct an anonymous survey of WIC clients to assess marijuana use and to gain understanding regarding the educational needs around marijuana. Goals and Objectives: With no baseline data to understand marijuana use among our WIC population, TCHD surveyed WIC clients to better understand their marijuana use patterns and educational needs. 1.       Develop methodology and survey instrument for efficient implementation at routine visits by WIC clients 2.       Understand current educational needs of WIC population regarding marijuana 3.       Understand past and current prevalence of different types of marijuana use 4.       Based on findings, develop staff training and client educational opportunities 5.       Share information received with local, state and national partners How Practice was Implemented/Activities: TCHD and Nutrition Division leadership began discussions about how best to assess marijuana issues within our WIC population in March of 2014. TCHD then reached out to the CDPHE and the Colorado State WIC Program to discuss partnering and implementation. May-July 2014:    Conversations with CDPHE regarding survey design, question development and implementation July 2014:                       Finalization of survey into SurveyMonkey© Pilot and translation of survey to Spanish     Testing of iPads® for survey administration Finalize iPad® rotation schedule among WIC clinics August - September 2014:              Survey conducted, rotated iPads® to 10 WIC clinics for a two week period and twice to our two monthly satellite clinics October 2014:                Survey collection completed October 10 Survey data analyzed Results/Outcome: Surveys were offered to 2,903 clients, 1,749 (60.2%) of which were completed. Of the 1,749 completed surveys, 1,616 (92.4%) were completed by “WIC mothers” (pregnant, or already with young children), with the remainder completed by other caregivers (e.g., fathers, grandparents).  Among WIC mothers, the prevalence was 29.1% for “ever use” of marijuana  and 5.9% for “current marijuana use.” Ever users of marijuana tended to be younger (≤ 30 years) and white non-Hispanic. Current marijuana users reported use during pregnancy (35.8%), after pregnancy (41.1%), and while breastfeeding (13.7%). All objectives were met through the survey process and educational materials were created. Collaboration and communication with internal and external stakeholders were important to the success of the survey. Public Health Impact of Practice: As a result of this survey, TCHD has implemented the following: Panel discussion to inform all TCHD staff on what various departments and programs within TCHD and what other agencies are doing to promote safe and responsible use of marijuana Distribution of  “Marijuana and Your Child” pamphlet that focuses on marijuana use during pregnancy, breastfeeding and parenting A Marijuana Resource and Referral Guide for TCHD staff for public inquiries A flow chart for mandatory reporters that provides guidance on how and when to report a mother using marijuana to the Department of Human Services for possible child neglect A cross-departmental Marijuana Workgroup to develop a plan to respond to emerging community needs Website: www.tchd.org    
Public Health Issue: With Colorado being the first state to legalize marijuana in January of 2014, there was little research and evidence about the use of marijuana by pregnant and breastfeeding women and effects on themselves and baby.  While the state has had legalized medical marijuana since 2000, legalization of recreational marijuana gave greater accessibility and use to Colorado residents.  As with alcohol, tobacco, or prescription drugs, misuse of marijuana can have serious health consequences. Some studies have found evidence that maternal use of marijuana during pregnancy has negative health effects on the fetus. There is mixed evidence on whether marijuana use during pregnancy is associated with adverse birth outcomes such as birth defects, preterm delivery and low birth weight. There is limited evidence on whether there is an association between marijuana use and stillbirth and Sudden Infant Death Syndrome (SIDS). However, there is growing evidence that using marijuana during pregnancy affects neurological development, mainly cognition and behavior. While new questions regarding marijuana were being added to statewide surveys to determine prevalence of use among various populations, these data were not going to be readily available to address the needs of our jurisdiction until the fall of 2015, over a year and half later after legalization.  Therefore, the Tri-County Health Department (TCHD) decided to implement a survey with the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) to determine prevalence of use and educational needs of its clients.  While not representative of the general population, women who are pregnant, breastfeeding, and/or with young children in the home is an important group to monitor for potential marijuana health impact. Target Population: The TCHD WIC Program is the largest WIC program in Colorado.  In 2014, the average monthly caseload for the TCHD Program was 24,324 individual clients, representing 16,628 family units.  Among the participating family units, 5,964 (36%) include clients who are pregnant, breastfeeding or postpartum. Our target population for the survey was “endorsers,” defined as either pregnant women or caregivers of children participating on the WIC Program.  Endorsers may be the mother, father, legal guardian of child(ren) participating on the program or the pregnant or postpartum mother who is participating on the program herself.  Based on a review of previous schedules, show rates at our clinics, and the timeframe of the survey, we set a goal of 50% or 1,500 endorsers to complete the survey.  To be eligible to participate, the endorser had to be 18 years of age or older and have the ability to speak and read English or Spanish on their own to ensure anonymity while taking the survey.  Over the ten weeks of the survey, 1749 (60%) of 2903 endorsers completed the survey, representing 10.5% of all endorsers who participate in the TCHD WIC Program. Of the 1749, 1,616 (92.4%) were expectant or current mothers. What has been done in the past to address this problem? The WIC Program assesses use of illicit or “street” drugs by pregnant, breastfeeding, and postpartum women as a standard part of their nutritional and health assessment.  Through the assessment, pregnant, breastfeeding and postpartum women are asked if they are currently using tobacco, alcohol and/or street drugs or did so in the three months prior to pregnancy.  Limitations of this method include likely underreporting due to the sensitive nature of the question and a coding system that grouped all illicit drugs together, precluding analysis of individual substances used.  Analysis of the WIC data system in 2014 revealed the following: 7.1% reported smoking 0.2% reported alcohol use 0.6% reported illegal drug use (but the type of drug is not identified) To educate and inform WIC clients, TCHD staff would provide a general overview of educational materials about how to have a healthy pregnancy and baby,  included abstinence from alcohol, drugs or tobacco, but there was no specific discussion of a potentially commonly used drugs such as marijuana. Why is Current Practice Better? The design of our survey of WIC clients is an improvement over and complement to existing plans for statewide surveys for several reasons.  First, we were able to target a population at high risk of potential harm from marijuana and rapidly determine their educational needs and interests. Second, the anonymous design using iPad-based data entry likely elicited more complete responses.  Third, the data were available to us in a rapid timeframe from patients actually using our program, enhancing both timeliness and specificity to our context. Of note, we utilized questions also present in statewide surveys to allow comparison to other populations and sampling strategies. The Marijuana and Your Child Pamphlet that was informed by the survey directly addresses marijuana use during pregnancy, breastfeeding and parenting along with information on the law and what to do if your child has been accidently exposed to marijuana.  The pamphlet has provided substantially more in-depth information of known interest to our clients than the general healthy pregnancy document. Is Current Practice Innovative? While health issues related to marijuana use are not new to the field of public health, the legalization of recreational marijuana creates important challenges in explaining the risks of a widely available product whose safety may be inferred by its legal status for both recreational and medical use (legal in Colorado since 2000). In addition, the use of iPads® and surveying a population at high risk for health impacts to provide real-time data on use and educational needs is also innovative. As more states legalize medical and recreational marijuana, this simple methodology can provide public health programs in other jurisdictions a useful tool to assess prevalence and educational needs. Is Current Practice Evidence Based? Yes.  As noted above, the recent Literature Review by CDPHE comprehensively reviewed the evidence regarding adverse health impacts of marijuana use. While there is mixed evidence on whether marijuana use during pregnancy is associated with adverse birth outcomes such as birth defects and low birth weight, it does affect neurological development, mainly cognition and behavior. These neurological health effects include: decreased academic ability, reduced IQ scores, cognitive functioning, and attention problems. At this time, there is no safe amount of marijuana that can be taken during pregnancy and it is advised that women do not use marijuana while pregnant.  Thus, we were addressing use and educational needs regarding a substance use practice for which there is a strong and growing evidence base. Furthermore, the survey design allowed us to base our educational material development of known areas of interest and concern by our clients. CDC Winnable Battle This practice is indirectly related to the Teen Pregnancy Winnable Battle since more careful use of marijuana during pregnancy can enhance healthy outcomes for those teens who do become pregnant.      
Teen Pregnancy
Goals and Objectives of Practice: Because there was a paucity of data on marijuana use during pregnancy, Tri-County Health Department (TCHD) sought to develop a questionnaire that could be administered to clients who participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).  TCHD reached out to The Colorado Department of Public Health and Environment (CDPHE) Survey Research Unit and the Colorado State WIC Program to collaborate on the development and administration of the survey.  CDPHE’s Survey Research Unit administers several surveys throughout the state including the Behavioral Risk Factor Surveillance System (BRFSS), the Pregnancy Risk Assessment Monitoring System (PRAMS), and the Colorado Child Health Survey (CHS). Because of their extensive expertise in this arena, TCHD consulted them in developing questions for the WIC marijuana survey. TCHD also reached out to the Colorado State WIC Program to utilize their expertise in the WIC program for survey development and administration.  Thus, the collaborative team worked together to develop the survey and the methodology for its administration. What did you do to achieve the goals and objectives; steps taken to implement program: Key TCHD staff met to discuss the rationale and value of surveying WIC clients Met with CDPHE staff to discuss survey idea and collaboration in moving forward In survey development, utilized questions already planned for use in statewide surveys, in addition to other questions TCHD was interested in pursuing Reviewed human subjects research implications with CDPHE IRB, who deemed the protocol to be public health evaluation and thus exempt from IRB oversight. Developed process to use iPads to implement survey in Survey Monkey format Hired summer interns to be site coordinators during survey implementation at WIC clinics Worked with TCHD IT department to configure iPads for survey Trained WIC staff on overview of project and referral script for survey WIC staff asked all eligible WIC clients to participate in survey after their appointment Upon completing survey in all 10 TCHD WIC clinics for two week period each, analyzed data Criteria for those to receive the practice: In order for the WIC endorser to participate in the survey, they had to be enrolled in WIC, have a WIC appointment on the day that the iPads were in the clinic, be 18 years of age or older (so that parental consent was not needed), be English or Spanish speaking (only two languages survey developed in), and have the ability to read and take the survey on their own (to ensure anonymity and reduce bias).  Timeframe: May to October 2014:  Survey Development and Administration  May-July 2014:              Conversations with CDPHE regarding survey design, question development and implementation July 2014:                       Finalization of survey into SurveyMonkey© Pilot and translation of survey to Spanish           Testing of iPads® for survey administration Finalize iPad® rotation schedule among WIC clinics August - September 2014:              Survey conducted, by rotating iPads® to 10 WIC clinics for a two week period and twice to our two monthly satellite clinics October 2014:                Survey collection completed October 10 Survey data analyzed October 2014 to Present: Since completion of analysis of the survey data, the results have been presented at local, state and national conferences and meetings.  TCHD also created a pamphlet, “Marijuana and Your Child” in response to the educational needs identified by those surveyed.  Now that TCHD has baseline marijuana use data among our WIC clients, we are currently planning for a follow-up survey to assess trends in use two years post legalization of recreational marijuana. Additionally, it supported the development of a TCHD Marijuana workgroup and informed one of the Goals of our new Strategic Plan.  Stakeholder Involvement: TCHD worked with CDPHE to plan, develop and implement the survey through conference calls and meetings.  CDPHE's State WIC Program oversees the TCHD WIC Program and both programs work closely together to serve and meet the needs of WIC clients across the state and within the TCHD jurisdiction.  Findings from the survey were shared initially with CDPHE’s Survey Research Unit and the Colorado State WIC Program.  Afterward, findings were shared with multiple organizations, presented at state and national conferences, and published in a state report. Other key stakeholders with whom we have been involved about study results and other issues related to marijuana are as follows: TCHD serves on the Governor’s Marijuana Education Oversight Committee that meets bi-monthly to review and provide input on educational materials, review of statewide campaign materials and evaluation data. TCHD works closely with the Retail Marijuana Advisory Committee by attending monthly meetings, reporting out findings from the WIC survey and utilization of TCHD data for report to legislature and in their final Monitoring Colorado Report 2014. TCHD’s medical epidemiologist, population health epidemiologist, and syndromic surveillance epidemiologist are members of the Council of State and Territorial Epidemiologists Marijuana Workgroup, a national public health workgroup studying the public health implications of legalizing recreational marijuana use. TCHD’s industrial hygienist serves on the CDPHE Marijuana Industry Workgroup on Health & Safety to address occupational health concerns including: Ergonomic concerns in the MJ sites due to repetitive motion; safety concerns with water on floor, extension cords in water on the floor, ventilation and sustainability of the grow lights. Costs of the program The costs of the program included staff time to do research, develop the survey, pilot test the survey, and analyze the results. Two interns were paid on a contract basis to administer the survey during the 10 week period.  Equipment costs included the purchasing of 10 iPads  and protective cases with WIC funding for clients to complete the survey which were subsequently repurposed for other uses in the WIC program. The remaining 4 iPads were borrowed from CDPHE.  Development of the Marijuana and Your Child pamphlet was in-kind staff time from the Nutrition and Nursing division, along with costs to print the pamphlets within the health department. Equipment: 10 iPads at $399 each for $3,900 Protective Cases at $40 each for $400 Staff Time: Amount of time on project was not tracked by individuals and amount of time varied by each individual in the process.  List of individual involved in the survey is listed below. CDPHE staff: CDPHE’s Survey Research Unit: Chief of Health Statistics and Evaluation Branch, Manager of Health Surveys and Analysis Unit Colorado State WIC Program: Prevention Service Branch Deputy Director, State WIC Nutrition Coordinator, Nutrition Consultant and Data Base Administrator TCHD staff: Planning and Development: Executive Director, Director of Nutrition, Public Health Epidemiologist, WIC Program Manager, and Nutrition Technical Specialist (data and reporting from WIC web-based system and implementation in clinics) Implementation: Two paid interns for a 10 week period for survey administration and tracking at clinic site; Individual WIC staff time for referral and explanation of the survey after each appointment for a two week period at each of the 10 WIC clinic sites and twice monthly at two satellite clinics. Analysis of Survey Data: Population Health Epidemiologist and Medical Epidemiologist Incentives to Complete Survey: Granola Bars and Water $145      
 What did Tri-County Health Department Find Out? 1.  Develop methodology and survey instrument for efficient implementation at routine visits by WIC clients The first goal was for Tri-County Health Department (TCHD) to develop the survey with assistance from CDPHE’s Survey Research Unit and the Colorado State Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program. TCHD set a target of having 1,500 WIC clients complete a survey. At the end of the ten week survey administration, 1,749 surveys were completed, surpassing the goal.  The survey data was collected via SurveyMonkey© and imported into a statistical software program. Descriptive and inferential statistics were computed using SAS 9.3.  A total of 1,749 surveys were completed (1,308 English surveys and 441 Spanish surveys) with a response rate of 60.2%. Fifty-four percent of respondents were Hispanic, 29% were white, and 10% were black/African American.  The majority of survey respondents were between the ages of 21 to 35 years of age. The race/ethnicity and age of WIC clients were similar to the survey respondents. Even though this was a convenience sample of WIC clients taking the survey, it was representative of TCHD’s WIC population in terms of age and race/ethnicity. 2.  Understand current educational needs of WIC population regarding marijuana The majority of survey respondents (92.9%) reported that they plan to talk to their child or are already talking with their child about health risks of marijuana. Eleven additional questions were asked to find out which type of educational needs regarding the health effects of marijuana WIC clients were interested in learning more about (listed below). Percent of ‘Yes” responses to the Educational Questions from Marijuana Survey 1. Would you like to learn more about marijuana use and the health effects on children?  54.7% 2. Would you like to learn more about the difference between medical marijuana and recreational marijuana?  53.7% 3. Would you like to learn more about how long marijuana stays active in the body? 52.8% 4. Would you like to learn more about the effects of marijuana use on parenting?  50.3% 5. Would you like to learn more about marijuana use and the effects on driving?  50.2% 6. Would you like to learn more about the different types of marijuana? (types that are consumed as food, candy or beverages, types that are smoked, types that are vaporized, etc.)  49.9% 7. Would you like to learn more about marijuana use and the health effects on adults? 49.0% 8. Would you like to learn more about marijuana use and addiction? 47.1% 9. Would you like to learn more about marijuana use and breastfeeding?  42.2% 10. Would you like to learn more about marijuana use during pregnancy? 41.5% 11. Would you like to learn more about how to quit using marijuana? 28.2% Approximately half of all the respondents indicated that they wanted education on ten of the eleven marijuana topics. This validates the need for providing education to WIC clients on the health effects of marijuana. Only 28 percent of respondents wanted to learn more about how to quit using marijuana. 3.  Understand past and current prevalence of different types of marijuana use Overall prevalence of ever using marijuana among WIC mothers was 29.1%. Overall prevalence of current marijuana use among WIC mothers was 5.9%. Current marijuana users reported use during pregnancy (35.8%), after pregnancy (41.1%), and while breastfeeding (13.7%). Of those who had tried marijuana, smoking (92.9%) was the most popular method for using marijuana. One third (34%) had consumed marijuana in food, almost one in five had vaporized marijuana (18.9%) and five percent consumed marijuana in a beverage. Other marijuana uses (1.8%) that survey respondents typed in included tincture drops, pills, hash and lotion. In addition, 19 percent of current marijuana users reported driving a vehicle while using marijuana in the past month. Twenty percent of current marijuana users had marijuana in their home. All of those who had marijuana in their home reported smoking marijuana inside their home. Nearly all (95%) current users reported storing the marijuana in a childproof container or packaging. 4.  Based on findings, develop staff training and client educational opportunities relevant to the WIC setting In October 2014, we held an All-Staff Meeting for TCHD staff (approximately 360 staff) that included a Marijuana panel.  The panel consisted of preliminary findings of the WIC Marijuana Survey, Police Department staff to discuss laws and regulations, Department of Human Services on Child Endangerment and a Marijuana Industry representative discussing how they were promoting safe and responsible use at retail shops. At the All Staff meeting, staff were surveyed on staff educational needs regarding marijuana. Knowing the health effects of marijuana and knowing when to mandatorily report marijuana use to Child Protective Services were the top two education needs requested by staff. Created the Marijuana and Your Child pamphlet that discussed marijuana during pregnancy, breastfeeding and parenting.  Shared pamphlet with local partners and health departments to also utilize. Divisions also held specific training opportunities for their staff and sent staff to statewide trainings made available. An internal Marijuana Workgroup was formed that had representation from all divisions at TCHD (Environmental Health, Emergency Preparedness and Response, Epidemiology, Planning and Communications, Nursing and Nutrition).  The group completed the following tasks to present: o   Scan of other local health departments of how they were working internally and with community partners on marijuana o   Internal  Resource and Referral Form for community questions and concerns shared with all staff o   Align messaging with local and state health departments 5.  Share information received with local, state, and national partners The findings of the survey were presented at local and national conferences.  For national conferences, TCHD staff presented the findings to Council of State and Territorial Epidemiologists (CSTE) Council of State and Territorial Epidemiologists (CSTE) annual conference on June 16, 2015 in Boston, Massachusetts and at the National Association of County and City Health Officials (NACCHO) annual conference on July 8, 2015 in Kansas City, MO. In May 2015, a poster session was also presented at the National WIC Conference in Los Angeles.  The findings were also shared at several local conferences and meetings throughout Colorado, including the Public Health in the Rockies annual conference in Vail, Colorado.  The findings were published in the following report that was prepared for Colorado State Legislature:  “Monitoring Health Concerns Related to Marijuana in Colorado: 2014; Changes in Marijuana Use Patterns, Systematic Literature Review, and Possible Marijuana-Related Health Effects.” (2015); Colorado Department of Public Health and Environment. Did you evaluate your practice? Primary Data Resources: TCHD WIC Marijuana Survey TCHD interns collected data and responses to the survey at 10 clinics over a ten week period utilizing Survey Monkey and iPads Secondary Data Resources: Statewide Surveys CDPHE’s Survey Research Unit administers several surveys throughout the state including the Behavioral Risk Factor Surveillance System (BRFSS), the Pregnancy Risk Assessment Monitoring System (PRAMS), and the Colorado Child Health Survey (CHS).  TCHD utilized some of the questions from these surveys to later compare TCHD survey responses to specific questions against CDPHE statewide survey responses when results become available. Performance Measures Process Measures: The TCHD WIC Marijuana Survey was pilot tested with WIC clients that would not be included in the survey administration time frame CDPHE Survey Research Unit and WIC Program staff also reviewed and pilot tested the survey Based on feedback from clients, CDPHE and WIC program staff, adjustments were made to survey Outcome Measures: TCHD staff presented preliminary findings on October 14, 2014 to the CDPHE Marijuana Steering Committee TCHD staff received feedback during multiple presentations on other questions to consider adding to follow-up survey Based on feedback received different cross tabulation of data was used in analysis The survey data was collected via SurveyMonkey© and imported into a statistical software program. Descriptive and inferential statistics were computed using SAS 9.3.  We will use feedback provided in development and modification of survey questions in the follow-up marijuana survey in 2016.    
Lessons learned in relation to practice: The primary lesson learned by Tri-County Health Department (TCHD) is that while the numbers are small, we learned that women are using marijuana during pregnancy and while breastfeeding. And because of the growing evidence that marijuana may be harmful to the unborn child, it is important to advise women who are pregnant or breastfeed to abstain from using marijuana. It was also found that there are many areas of marijuana that WIC clients are interested in learning about on the health effects of use. TCHD created a pamphlet to address those needs for the WIC population that was specific to marijuana use while pregnant, breastfeeding and parenting.  While it was found that a higher percentage of those taking the survey in Spanish answered ‘yes’ to learning more about marijuana and its health effects compared to those taking the survey in English, it is unknown as to why there was such a difference in educational needs. Additional lessons learned include revising the survey questions. There needs to be separate questions added to determine if the respondent is currently pregnant or breastfeeding. TCHD will also plan to add questions regarding other types of substance use during pregnancy including tobacco and alcohol use. These revisions will be made in TCHD’s follow-up marijuana survey in 2016. Lessons learned in relation to partner collaboration: We will continue to work with Colorado Department of Public Health and Environment (CDPHE) on questionnaire modification for a follow-up survey.  There has already been discussion on new questions that have been added to other surveys that we may want to include. TCHD will also work with the other health departments who expressed interest in conducting the survey in their jurisdiction and help them with the survey administration process. TCHD is currently working with the Colorado State WIC program to reach out to all the WIC directors to open up the survey to all health departments throughout Colorado. During presentations, attendees also had recommendations of asking about tobacco use and alcohol use to consider in the next survey collection.  Cost Benefit Analysis No Cost Benefit Analysis was conducted since this was not a conventional public health intervention. However, making use of an easily reachable convenience sample of high public health relevance allowed a modest investment to generate very impactful results. Stakeholder Commitment and Sustainability: There is commitment by TCHD and CDPHE to continue assessment of marijuana use with the WIC population.  TCHD now has baseline data and plans to monitor trends in marijuana use and educational concerns among our clients. TCHD plans to administer the survey on a regular basis with the next survey collection to begin in early 2016. In addition, other local public health departments have expressed interest in administering the survey. TCHD is currently working with the Colorado State WIC program and CDPHE’s Survey Research Unit to recruit other local public health departments to administer the survey. Geographic comparisons will be able to be made across the state.  TCHD also already has the equipment/iPads to administer the survey.  
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