Discrimination and Mental Health in a Representative Sample of African-American and Afro-Caribbean Youth

BACKGROUND

Racism and discrimination are psychosocial stressors that affect the health of minority populations. While discrimination has been associated with poor mental health, little is known about the relationship between discrimination and mental health outcomes in youth nationally. Furthermore, mental and behavioral health consequences of discrimination may differ in different minority groups.

OBJECTIVE

The goal of this study is to determine (1) how common perceptions of discrimination are in a nationally representative sample of African-American (AA) and Afro-Caribbean (AC) teens, (2) the relationship between discrimination and mental health conditions, and (3) whether discrimination has different associations with mental health in AA and AC youth.

DESIGN

Cross-sectional comparison study SETTING: National Survey of American Life-Adolescent Supplement, a nationwide sample of African-American and Afro-Caribbean youth drawn from a nationally representative household survey of AA and AC population PARTICIPANTS: One thousand, one hundred and seventy AA and AC youth between 13 and 17 years EXPOSURE: Experiences with discrimination (Everyday Discrimination Scale) MAIN OUTCOMES: Lifetime and past 12-month major depression and anxiety RESULTS: Ninety percent of AA and 87% of AC youth experienced discrimination. Discrimination was significantly associated with lifetime and 12-month major depression and lifetime and 12-month anxiety. There were no differences in the associations between discrimination and mental health between AA and AC youth except for lifetime anxiety: as discrimination increased, the likelihood of lifetime anxiety disorder increased at a higher rate among AC youth compared to AA.

CONCLUSIONS

Discrimination is a common psychosocial stressor in African-American and Afro-Caribbean youth. It is associated with poor mental health outcomes. There was no difference in the occurrence of discrimination between African-American and Afro-Caribbean youth or in its mental health consequences.

Thirty-day outcomes support implementation of a surgical safety checklist

BACKGROUND

Thirty-day postoperative complications from unintended harm adversely affect patients and their families and increase institutional health care costs. A surgical checklist is an inexpensive tool that will facilitate effective communication and teamwork. Surgical team training has demonstrated the opportunity for stakeholders to professionally engage one another through leveling of the authority gradient to prevent patient harm. The American College of Surgeons National Surgical Quality Improvement Program database is an outcomes reporting tool capable of validating the use of surgical checklists.

STUDY DESIGN

Three 60-minute team training sessions were conducted and participants were oriented to the use of a comprehensive surgical checklist. The surgical team used the checklist for high-risk procedures selected from those analyzed for the American College of Surgeons National Surgical Quality Improvement Program. Trained observers assessed the checklist completion and collected data about perioperative communication and safety-compromising events.

RESULTS

Data from the American College of Surgeons National Surgical Quality Improvement Program were compared for 2,079 historical control cases, 246 cases without checklist use, and 73 cases with checklist use. Overall completion of the checklist sections was 97.26%. Comparison of 30-day morbidity demonstrated a statistically significant (p = 0.000) reduction in overall adverse event rates from 23.60% for historical control cases and 15.90% in cases with only team training, to 8.20% in cases with checklist use.

CONCLUSIONS

Use of a comprehensive surgical safety checklist and implementation of a structured team training curriculum produced a statistically significant decrease in 30-day morbidity. Adoption of a comprehensive checklist is feasible with team training intervention and can produce measurable improvements in patient outcomes.

Educational outreach to reduce immunization pain in office settings

OBJECTIVE

The goal was to examine the impact of a teaching module on immunization pain reduction practices in pediatric offices 1 and 6 months after the intervention.

METHODS

Fourteen practices were selected randomly to receive a 1-hour teaching session on immunization pain reduction techniques, and 13 completed the study. Before the intervention, telephone interviews were conducted with parents concerning their children's recent immunization experiences. At 1 and 6 months after the intervention, parents of children who had recent immunizations were interviewed by using the same questionnaires. Clinicians also were surveyed at baseline and at 6 months.

RESULTS

A total of 839 telephone interviews and 92 clinician surveys were included. Significant changes from baseline were identified at 1 and 6 months after the intervention. At 1 month, parents were more likely to report receiving information (P = .04), using strategies to reduce pain (P < .01), learning something new (P < .01), using a ShotBlocker (P < .01), using sucrose (P < .01), and having higher levels of satisfaction (P = .015). At 6 months, all rates remained significantly higher than baseline findings (all P < .01) except for satisfaction. Clinician surveys revealed significant increases in the use of longer needles, sucrose, pinwheels, focused breathing, and ShotBlockers at 6 months.

CONCLUSIONS

A 1-hour teaching session had measurable effects on the use of pain-reducing strategies at 1 and 6 months after the intervention. This research supports the hypothesis that small-group teaching sessions at the site of care can be associated with changes in practice behaviors.

Perceived racism and discrimination in children and youths: an exploratory study

Racism may be a factor contributing to poor health and health care disparities in minority children through multiple mechanisms, including effects on psychological and physical wellbeing. Little is known about the experiences of racism that children encounter in their lives. This study describes the occurrences of perceived racism in children, including the settings and contexts in which it occurs. A questionnaire was administered to a convenience sample of urban children (eight to 16 years of age) asking about settings and situations in which they perceived discrimination. Two hundred and seventy-seven children completed the questionnaire; 88 percent ofthe children had at least one experience with racial discrimination, and 11.6 percent had experienced racism in at least half (12) of the 23 situations addressed in the questionnaire. Settings included schools and community contexts, and both peers and adults were perceived to be perpetrators. There were few differences in perceptions of racist episodes among different ethnocultural minority groups. Racism is perceived to be a common occurrence in many minority children's lives. Studies investigating perceptions of racism and how they relate to health disparities need to be conducted.

Perceptions of Racism in Children and Youth (PRaCY): properties of a self-report instrument for research on children's health and development

Experiences of racial discrimination have been demonstrated to be related to racial and ethnic disparities in mental and physical health and healthcare. There has been little study, however, of the relationship between racism and health in children, and few psychometrically valid and reliable instruments to measure Perceptions of Racism in Children and Youth (PRaCY) exist. This paper reports on the development and testing of such an instrument, the PRaCY. Development of the instrument began with open-ended qualitative interviews, from which a proto-questionnaire was created. The questionnaire gathered information on the prevalence, attribution, emotional responses, and coping responses to 23 situations identified by participants in the qualitative phase. The proto-questionnaire was administered to 277 children between the ages of 8 and 18 years (38% Latino/a, 31% African-American, 19% multiracial/multicultural, 7% West Indian/Caribbean, and 5% Other). Item analysis resulted in two developmentally appropriate 10-item instruments (one for ages 7-13, another for ages 14-18). Internal consistency reliability was strong (alpha = 0.78 for both versions of the instrument). Confirmatory factor analysis demonstrated good fit for both versions (younger-Comparative Fit Index (CFI): 0.967, Root Mean Square Error of Approximation (RMSEA): 0.047; older-CFI: 0.934, RMSEA: 0.056). Differential item functioning analyses demonstrated no group-specific biases in item response. PRaCY scores were appropriately associated with higher depressive symptom scores and elevated anxiety scores in the younger sample. Results indicate that the PRaCY is a valid and reliable instrument that measures perceptions of racism and discrimination in children and youth aged 8-18 from diverse racial/ethnic backgrounds.

Role of pediatric health care professionals in the provision of parenting advice: a qualitative study with mothers from 4 minority ethnocultural groups

OBJECTIVE

This study's aim was to elicit the perspectives of minority parents on their expectations of pediatric health care providers as a source of advice on "raising their child" and whether they would seek advice from these providers. A secondary aim was to demonstrate the value of qualitative methods for assessing parental attitudes in pediatric research.

METHODS

Mothers with children between 3 and 12 years of age who identified themselves as African American, Jamaican, Haitian, or Puerto Rican were recruited from community sites. Audiotaped focus groups were conducted by trained moderators using an interview guide, to obtain the perspectives of the participants regarding the role of pediatric providers in the provision of parenting advice.

RESULTS

Ninety-one mothers participated in a total of 20 focus groups, with 4 to 6 discussions per ethnocultural group. The focus groups revealed that, in general, parents do not look to child health care providers for advice on raising their children. The identified themes emphasized the importance of the relationship between providers and families. A few parents had the type of relationship within which the pediatrician already functioned as a provider of parenting advice. Physicians were considered skilled in the maintenance of physical health. The parents expressed a desire to receive more anticipatory guidance on developmental and behavioral stages and milestones. Pediatricians also served specific administrative functions valued by parents.

CONCLUSIONS

Minority parents of preschool-aged and school-aged children do not view the primary care provider's role as including the provision of parenting advice. Expectations must be modified to enable health care professionals to function effectively in the role of advisor regarding parenting issues.

Managing anemia in low-income toddlers: barriers, challenges and context in primary care

Iron-deficiency remains a concern among low-income toddlers in the U.S. This formative study describes how primary care providers serving high-risk 1- to 3-year-old children in an urban ambulatory care setting approach anemia. Data collection included a retrospective review of randomly selected medical records (n=264) and semi-structured interviews with clinicians (n=41). Thirty-eight percent of the children presented with anemia (Hgb < 11.0 g/dl) at least once between 12 and 36 months of age. Just under half of these children were treated for anemia. Follow-up laboratories for iron-treated children were completed within 35 days in 16% of cases (median: 3 months). Interviews identified four key themes (iron-deficiency, communication, poverty, system) running through the two major categories of prevention and treatment. Treatment cut-points were variable. While providers felt clinically comfortable with anemia, they felt burdened and challenged by follow-up. Communication and system barriers weighed most heavily on perceived treatment outcomes.

A simple provider-based educational intervention to boost infant immunization rates: a controlled trial

We sought to determine if a simple educational intervention initiated at the first well-child care visit, with reinforcement at subsequent visits, can improve inner-city infant immunization rates. We conducted a controlled trial involving 315 newborn infants and their primary caregivers in 3 inner-city primary care centers. Child health care providers gave caregivers in the intervention group an interactive graphic card with verbal reinforcement. At later visits, stickers were applied to the card when immunizations were given. Routine information was given to controls. After the trial, age-appropriate immunization rates at 7 months were 58% in each group. Intervention infants had 50% fewer missed opportunities to immunize (p=0.01) but cancelled 77% more appointments (p=0.04) than controls. We conclude that a brief educational intervention at the first well-child care visit did not boost 7-month immunization rates, although it was associated with fewer missed opportunities to immunize.

Factors affecting oral feeding with severe traumatic brain injury

Safe and adequate nutrition, vital to the recovery from a traumatic brain injury, can be severely compromised by the presence of dysphagia. This study identified injury severity and swallowing factors that were associated with impaired oral intake in patients with severe brain injury. An admitting Glasgow Coma Scale (GSC) 3-5; a Rancho Los Amigos Scale of Cognitive Functioning (RLA) Level II; a computed tomography (CT) scan exhibiting midline shift, brainstem involvement, or brain pathology requiring emergent operative procedures; or ventilation time >/=15 days identified patients at highest risk for abnormal swallowing, aspiration, and delay in initiation of oral feeding and achievement of total oral feeding. When combined in multivariate models, RLA Level, CT scan, ventilation time and aspiration emerged as significant independent predictors of impaired oral intake.

Swallowing disorders in severe brain injury: risk factors affecting return to oral intake

OBJECTIVE

To determine the incidence and type of swallowing disorders that accompany severe brain injury and to identify factors that affect oral intake.

DESIGN

Inception cohort study.

SETTING

Level I trauma center.

PATIENTS

Consecutively admitted patients with severe brain injury who achieved cognitive levels during admission to assess swallowing and who did not sustain injuries preventing swallowing assessment (n = 54).

MAIN OUTCOME MEASURES

Type of swallowing abnormalities and presence of aspiration evident on videofluoroscopic swallow studies (VFSS), days to initiation and achievement of oral feeding, ventilation days, presence of a tracheostomy, and cognitive levels at initiation and achievement of oral feeding.

RESULTS

Sixty-one percent of subjects exhibited abnormal swallowing. Loss of bolus control and reduced lingual control occurred most commonly. Aspiration rate was 41%. Normal swallowers achieved oral feeding in 19 days versus 57 days for abnormal swallowers. Rancho Los Amigos (RLA) Level IV was needed for initiation of oral feeding; Level VI was needed for total oral feeding. Risk factors for abnormal swallowing included: lower admission Glasgow Coma Scale (GCS) and RLA scores, presence of a tracheostomy, and ventilation time longer than 2 weeks. Risk factors for aspiration were lower admission GCS and RLA scores.

CONCLUSIONS

Swallowing disorders and behavioral/cognitive skills are frequently present in patients with severe brain injury and significantly affect oral intake of food. Persons who swallow abnormally take significantly longer to start eating and to achieve total oral feeding, and they require nonoral supplementation three to four times longer than those who swallow normally.

A comparison of the Mogen and Gomco clamps in combination with dorsal penile nerve block in minimizing the pain of neonatal circumcision

OBJECTIVES

1) To compare the Mogen and Gomco clamps with regard to pain experienced during neonatal circumcision, and 2) to assess neonatal circumcision pain with and without dorsal penile nerve block (DPNB).

DESIGN/METHODS

A randomized, controlled, nonblinded clinical trial; 48 healthy, full-term infants were randomized into one of the following four groups: Gomco vs Mogen with (+) or without (-) DPNB. DPNB+ infants were injected with 0.8 mL of 1% lidocaine before circumcision. DPNB- infants received no placebo injection. Heart rate, respiratory rate, and oxygen saturation (SaO2) during the procedure were monitored and data transferred to computer files by using the Datalab software system. Crying was recorded on videotape. Pre- and postcircumcision saliva samples for cortisol analysis were collected. Heart rate, respiratory rate, SaO2, cortisol changes, and duration of crying were evaluated statistically with two-way analyses of variance and t tests.

RESULTS

The type of clamp but not the use of anesthesia was significantly associated with the length of the procedure (mean Mogen time, 81 seconds; mean Gomco time, 209 seconds) and percentage of respiratory rate change. The use of anesthesia but not the type of clamp was significantly associated with percentage of crying time and percentage of SaO2 change during the procedure. Heart rate changes and total crying time were significantly associated with both the type of clamp and the use of anesthesia. Neither clamp type nor anesthesia status was significantly associated with salivary cortisol changes, although the mean increase for the DPNB- group was approximately twice that for the DPNB+ group. Fifty-six percent of infants circumcised with the Mogen clamp and DPNB did not cry at all during the procedure.

CONCLUSIONS

DPNB is effective in reducing neonatal circumcision pain with either the Mogen or the Gomco clamp. For a given anesthesia condition, the Mogen clamp is associated with a less painful procedure than the Gomco. The Mogen clamp with DPNB causes the least discomfort during neonatal circumcision.

Home-based therapies for the common cold among European American and ethnic minority families: the interface between alternative/complementary and folk medicine

BACKGROUND

Most studies of alternative/complementary medicine use in children have focused on children with chronic illness and have not addressed the more common form of complementary medicine: popular home-based interventions and therapies for common low-morbidity sickness episodes. Also, there has often been a distinction between alternative/ complementary medical practices used by the general population and those used by members of ethnic minority groups and commonly referred to as folk medicine or ethnomedicine.

OBJECTIVE

To describe the home-based therapies and practices that parents from diverse ethnocultural backgrounds use to treat the common cold in their children.

METHOD

Interviews with mothers of children coming for care at a number of clinics and physicians' offices. Included were mothers from European American, African American, Puerto Rican, and West Indian-Caribbean heritages.

RESULTS

Mean number of home-based remedies for the common cold did not differ among ethnic groups (controlling for maternal age, maternal education, number of children, and health insurance status). There were differences among groups regarding the frequency of use of specific remedies.

CONCLUSIONS

Home-based remedies for colds in childhood are commonly used. Many of the treatments are complementary to biomedical treatment (ie, antipyretics, over-the-counter cold remedies, fluids). Very few are potentially hazardous if taken in moderation. Mothers from ethnic minorities use similar amounts of homebased interventions when compared with mothers from the majority culture.

Significance of scapular fracture in the blunt-trauma patient

STUDY OBJECTIVE

To determine the significance of scapular fractures in blunt-trauma patients compared with blunt-trauma patients without scapular fractures.

DESIGN

Retrospective chart review of 11,500 blunt-trauma patients with a control group matched for age, sex, and mechanism of injury.

SETTING

Two Level I trauma centers.

PARTICIPANTS

Ninety-two blunt-trauma patients with scapular fractures and 81 control patients.

RESULTS

Mortality, neurovascular injury, and injury severity scores were compared for blunt-trauma patients with scapular fractures with those of the control group. Analysis revealed a 1% incidence of scapular fractures in blunt trauma with no neurovascular injury and no mortality. Scapular fractures were associated with thoracic injury in 49% of the patients, compared with 6% in the control group (difference, 43%; 95% confidence interval, 31.6 to 51.4; P < .001, Fisher's exact test).

CONCLUSION

Scapular fractures are not a significant marker of greater mortality or of neurovascular morbidity in blunt-trauma patients.

Ethnomedical (folk) remedies for childhood asthma in a mainland Puerto Rican community

BACKGROUND

Childhood asthma is the most common chronic illness of childhood. The highest prevalence of childhood asthma in the United States occurs in the Puerto Rican community, and there are many traditional beliefs and practices regarding asthma that coexist with biomedical therapies.

OBJECTIVES

To describe the ethnomedical treatment practices for childhood asthma in one mainland United States Puerto Rican community and to determine whether any of these practices are effective or potentially harmful.

METHOD

Home interview with caretakers of 118 Puerto Rican children with asthma who seek care at two community health clinics in an inner city in the eastern United States.

RESULTS

Common home-based ethnomedical practices include attempts to maintain physical and emotional balance and harmony, religious practices, and ethnobotanical and other therapies. Potentially harmful practices are uncommon, and other remedies are only harmful if not taken as directed. Many remedies are not effective from a biomedical standpoint (ie, bronchodilation or antiinflammation), but if analyzed within the ethnomedical explanatory model--which includes the belief that expulsion of mucus and phlegm from the body is beneficial for the treatment of asthma--these remedies bring about the desired effect and are therefore considered effective to the user.

CONCLUSIONS

Ethnomedical therapies for asthma in the mainland Puerto Rican community are well known and commonly used. Most practices are not idiosyncratic but fit within a coherent ethnocultural belief system. The health care practitioner can lower the risk for potentially toxic effects of some treatments by discussing these practices with patients and families. Some ethnomedical practices are not discordant with biomedical therapy. Incorporation of these practices into the biomedical plan may help to fit the biomedical therapy into the lifestyle of the patient.

Pediatricians' approaches to developmental problems: has the gap been narrowed?

Whether recent advances in developmental pediatrics have influenced pediatric practice is uncertain. We interviewed, in their offices, 41 randomly selected, board-certified, primary care pediatricians in Connecticut to explore their attitudes and clinical approaches to developmental problems. Responses were compared with those from a similar survey of 97 New England pediatricians performed 15 years ago. Important changes in certain clinical approaches were found. For example, pediatricians are currently less likely to rely on history and physical examination alone to confirm a suspicion of mental retardation (p < .01) and are more likely to refer such a child for further assessment (p < .01); they are more likely to perform hearing screening in evaluating a child with delayed speech (p < .05); they are more likely to contact the school in evaluating a failing child (p < .01), and are more likely to refer such a child for further assessment (p < .01). Results indicate favorable changes in pediatricians' approaches to developmental problems and support the greater emphasis on developmental issues in pediatric education.

Meconium testing for cocaine metabolite: prevalence, perceptions, and pitfalls

OBJECTIVES

We determined the prevalence of prenatal cocaine use in a racially mixed sample of urban and suburban mothers and correlated its use with maternal demographics and newborn measurements.

STUDY DESIGN

Meconium from 621 consecutive newborns delivered at two university-affiliated urban hospitals were assayed for benzoylecgonine. Maternal and infant characteristics were linked anonymously with the results. Statistical analysis included t test, Fisher's exact test, Duncan's multiple range analysis, and analysis of covariance, with a value of p < 0.05 considered significant.

RESULTS

We found that 3.4% of meconium samples had benzoylecgonine levels exceeding 0.1 micrograms/ml. Its presence was statistically correlated with maternal and neonatal characteristics. A nurse's opinion of cocaine use was correct 22% of the time.

CONCLUSIONS

Prenatal cocaine use was statistically associated with multiparity, multigravidity, late-onset and clinic-based prenatal care, public assistance, nonwhite race, and low academic achievement. A nurse's opinion was a poor predictor of maternal cocaine use. Cocaine-exposed infants were significantly smaller, and this correlated best with nonwhite background.

Early intervention in severe head injury: long-term benefits of a formalized program

With traumatic brain injuries numbering more than two million per year, health professionals are faced with the challenges of restoring and maximizing quality of life. This study quantifies the benefits of a formalized head injury program, including the concept of trauma rehabilitation, defined as early, aggressive rehabilitation during acute hospitalization. Thirty-eight severely head injured patients received treatment at the same rehabilitation facility. Twenty-one of these patients received acute care services at ten different hospitals without formalized traumatic brain injury programs, and 17 received services at a hospital with a formalized early intervention program. Comparison of outcome data for the two programs revealed that patients in the formalized program had comas and rehabilitation stays approximately one third the length of patients in nonformalized programs (18.9 vs 53.8 days and 106.5 vs 239.5 days, respectively). Mean cognitive levels at discharge from the acute hospitals (5.6 vs 4.0) and the rehabilitation facility (7.4 vs 6.7) were significantly higher for the formalized program, and they facilitated a significantly higher percentage of discharges to home vs extended care facility (94% vs 57%).

Individual differences in children's response to pain: role of temperament and parental characteristics

Sixty-five families were enlisted in a study exploring factors associated with distress behavior in 5-year-old children receiving diphtheria-tetanus-pertussis immunizations. At a home visit 1 month before the immunization, the following measures were obtained: (1) the Behavioral Style Questionnaire, a measure of temperament: (2) parental self-reports of medically related attributes (eg. "good patient"); (3) parental attitudes toward pain in children and responsiveness to their child's pain; and (4) parental prediction of distress at upcoming immunization. The child's distress behavior during the immunization was evaluated using a modification of the Procedure Rating Scale-Revised and, after the procedure, the child's assessment of his or her pain was elicited using the Oucher. Children's mean Procedure Rating Scale-Revised score was 2.57 of a possible 11. Thirty-one (48%) had low (less than or equal to 1) and 7 (11%) had high distress scores (greater than or equal to 2 SD above the mean). Factors positively correlated with distressed behavior included more "difficult child" cluster characteristics, the individual temperamental dimension of adaptability, but few parental attitudes and attributes. Parent's predictions of distress were the strongest correlates. These findings document the variation that children demonstrate in response to pain and offer some insight into associated innate and environmental factors. These results imply that treatment strategies derived from parental knowledge and tailored to individual characteristics of the child may be most effective in alleviating pain-related distress in medical settings.