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Thank you for your comments! In our community we have looked into the high rates of prescription opiates and ease of access to prescriptions, high poverty and self-medication, as well as multi generational use and the culture surrounding substance and alcohol use across generations. 

Hi Lacy, thank you for taking time to review this project!

We have currently distributed 40 copies of the Care Notebooks to women entering recovery  and 20 screening tools to the physicians and community health workers who are working with these women; and are hoping to print more as the demand has been very high!

For the past year we have conducted several semi-structured interviews with mothers and women in recovery, hospital social workers, OB-GYNs who work with pregnant women who have substance use disorder, social services, substance use counselors, public health professionals, and many other community stakeholders to develop these tools. They have gone through several rounds of edits to ensure they are not only culturally competent to our population of interest but easily readable and digestible. We have put it through a readability generator and although the medical terms have increased the reading level, for most of the information it falls into a 5th grade reading level. The Care Notebook is used as a communication tool to help women begin taking ownership of their pregnancy and recovery and to aid in better self and medical advocates. These notebooks have also been reviewed by a SAMHSA representative and we received very helpful and positive feedback from them.  For the screening toolbox we have recorded all of the medical professional we have distributed to and will conduct ease of use and usefulness surveys shortly. For the Care Notebooks we have great relationships with the OB's and CSB substance use counselors that are implementing these books into their programs and treatment. In the future we have discussed going back into the treatment group meetings and conducting more semi-structured interviews to gather qualitative data on the usefulness and ease of use for the Care Notebook. With the rise of prenatal substance use disorder (SUD) and neonatal abstinence syndrome (NAS) in our area being so dramatic we anticipate that our tools will help to increase knowledge and behavior change for women using substances, and because the community is small and word spreads quickly in our rural communities we anticipate that the number of women entering recover may increase as resources increase, but we hope that within the next few years the quantitative data we have been collecting on NAS and SUD rates begin to decline.