Examining associations between school-level determinants and the implementation of physical activity opportunities

School-based physical activity (PA) opportunities can help students engage in greater amounts of daily PA, meet PA guidelines, and lead to improved health and educational outcomes. However, we do not completely understand the organizational challenges to implementing these opportunities successfully. This exploratory study examined associations between school-level determinants and the implementation of school-based PA opportunities. We analyzed cross-sectional survey data from schools (n = 46) participating in the Healthy Zone School Program (HZSP) (Dallas, Texas, USA) during 2019-2020. Respondents completed an electronic survey that included measures of school-level determinants (e.g. culture, leadership, priority) and the implementation of school-based PA opportunities. We used linear regression models to examine associations between determinants and implementation outcomes (number of PA opportunities delivered, perceived overall success of each PA program/activity used). After adjusting for campus type (i.e. elementary, middle, high, K-12), student race/ethnicity, and percentage of economically disadvantaged students, no constructs were associated with the number of PA opportunities implemented. Linear regression models suggest access to knowledge and information (β = 0.39, P = .012, 95% CI = 0.24-1.44) and implementation climate (β = 0.34, P = .045, 95% CI = 0.02-1.59) were positively associated with the success of school-based PA opportunities. Our findings provide suggestive evidence that access to knowledge and information and a supportive school climate may improve the overall success of PA opportunities provided to students. Future research should examine additional school-level determinants to understand their importance to implementation and inform the development of strategies to improve schools' capacity for implementing PA opportunities successfully.

Using the R = MC2 heuristic to understand barriers to and facilitators of implementing school-based physical activity opportunities: a qualitative study

BACKGROUND

Schools are a key setting for supporting youth physical activity, given their broad reach and diverse student populations. Organizational readiness is a precursor to the successful implementation of school-based physical activity opportunities. The R = MC2 heuristic (Readiness = Motivation x Innovation-Specific Capacity x General Capacity) describes readiness as a function of an organization's motivation and capacity to implement an innovation and can be applied to better understand the implementation process. The purpose of this study was to explore the barriers to and facilitators of implementing school-based physical activity opportunities in the context of organizational readiness.

METHODS

We analyzed interview data from 15 elementary school staff (principals, assistant principals, physical education teachers, and classroom teachers) from a school district in Texas. We focused on factors related to adopting, implementing, and sustaining a variety of school-based physical activity opportunities. We used the Framework Method to guide the analysis and coded data using deductive (informed by the R = MC2 heuristic) and inductive approaches. Themes were generated using the frequency, depth, and richness of participant responses.

RESULTS

Four themes emerged from the data: (1) implementation is aided by the presence of internal and external relationships; (2) physical activity opportunities compete with other school priorities; (3) seeing the benefits of physical activity opportunities motivates school staff toward implementation; and (4) staff buy-in is critical to the implementation process. Themes 1-3 aligned with subcomponents of the R = MC2 heuristic (intra- and inter-organizational relationships, priority, and observability), whereas Theme 4 (staff buy-in) related to multiple subcomponents within the Motivation component but was ultimately viewed as a distinct construct.

CONCLUSION

Our results highlight and explain how key readiness constructs impact the implementation of school-based physical activity opportunities. They also highlight the importance of obtaining staff buy-in when implementing in the school setting. This information is critical to developing readiness-building strategies that help schools improve their capacity to deliver physical activity opportunities effectively.

TRIAL REGISTRATION

Not applicable.

Human papillomavirus (HPV) vaccination in males: Associations of HPV-related knowledge and perceptions with HPV vaccination intention among Korean mothers of boys

Objectives

Human papillomavirus (HPV) vaccination rates among males are suboptimal worldwide. In South Korea, little is known about parents' intention to vaccinate boys against HPV. Therefore, we examined the associations of HPV-related knowledge and perceptions with vaccination intention among Korean mothers of boys.

Methods

From August to December 2021, eligible mothers were surveyed about HPV-related knowledge, perceptions, and intention to vaccinate their sons against HPV. Mothers were categorized into no intention, contemplating, and intention to vaccinate groups. Using analysis of variance, we compared the groups' scores on the scales measuring HPV-related knowledge, attitudes, and beliefs. We conducted a multinomial logistic regression analysis to assess the associations between the variables and vaccination intention.

Results

Among 361 mothers, 43.9 % had no intention, 60.7 % were contemplating, and 4.4 % intended to vaccinate their sons. The mean percentage of correct answers on the HPV and vaccine knowledge scales were 52.5 % and 62.3 %, respectively. The mean scores on the HPV attitudes and beliefs subscales were significantly different. Higher scores on benefits (OR = 3.04, 95 % CI 1.96 - 4.70; OR = 3.94, 95 % CI 1.54 - 10.70) and influence (OR = 1.48, 95 % CI 1.03 - 2.13; OR = 2.97, 95 % CI 1.44 - 6.14) were associated with contemplating the vaccine and intending to vaccinate sons. Knowledge was not associated with mothers' vaccination intention.

Conclusions

Public health authorities and healthcare providers in Korea can use the results of this study to implement effective interventions that emphasize the importance of male HPV vaccination and encourage parent-son communication about the vaccine.

A Multivariate Probit Regression of the Uptake of Adolescent Vaccines Among Racial/Ethnic Minority Adolescents Before and During the COVID-19 Pandemic

PURPOSE

The uptake of adolescent vaccines has improved over the years. However, research of the effects of the COVID-19 pandemic on this uptake among racial/ethnic minority adolescents has been limited. This study was conducted to compare the probability of uptake of the human papillomavirus (HPV); tetanus, diphtheria, and acellular pertussis (Tdap); and quadrivalent meningococcal conjugate (MenACWY) vaccines among racial/ethnic minority adolescents ages 13-17 years in 2019, 2020, and 2021.

METHODS

Using a cross-sectional design to examine data from the National Immunization Survey-Teen (2019-2021), multivariate probit regression was used to model variation in uptake of these three adolescent vaccines (n = 38,128). The outcome measures were HPV, Tdap, and MenACWY vaccine uptake.

RESULTS

The probability of uptake of HPV vaccine was higher in 2020 (Coef = 0.09 [95% confidence interval (CI), 0.03-0.16]) and 2021 (Coef = 0.07 [95% CI, 0.00-0.15]) than in 2019. The probability of uptake of MenACWY vaccine was higher in 2020 (Coef = 0.08 [95% CI, 0.02-0.15]) than in 2019. The probability of uptake of recommended vaccines varied among racial/ethnic minorities with non-Hispanic Black adolescents exhibiting higher probability of uptake of HPV vaccine (Coef = 0.10 [95% CI, 0.01-0.19]) than Tdap vaccine. U.S. Census region and insurance status were associated with the uptake of all recommended vaccines.

DISCUSSION

Progress in the uptake of these recommended vaccines may not have been interrupted by the COVID-19 pandemic. Also, disparities in uptake of the recommended vaccines still exist despite increased uptake during the pandemic. Future research should examine the disparities as well as examine regional differences in the uptake of these three adolescent vaccines.

Adapting an evidence-based mindfulness-based intervention for sheltered youth experiencing homelessness

OBJECTIVES

Youth experiencing homelessness (YEH) face challenges that impact their physical, mental, and social wellbeing, emotion regulation, and coping. Mindfulness reduces stress and improves resilience, emotion regulation, and executive functioning. Mindfulness-based interventions (MBI) teach the practice of mindfulness to foster present-moment attention without judgement and enhance self-observation and self-regulation, resulting in greater awareness of thoughts and emotions and improved interpersonal relationships. One such intervention, .b, has been shown to lower stress among youth. While a pilot study of .b among sheltered youth found the intervention to be feasible, the need for modifications was identified to improve its relevance, accessibility, and incorporate a trauma-informed approach.

METHODS

We used the ADAPT-ITT (Assessment, Decisions, Administration, Production, Topical experts, Integration, Training staff, and Testing) framework to adapt the .b mindfulness intervention to YEH living in an emergency shelter. Nine focus group discussions (n = 56), key informant interviews (n = 8), and beta testing with five youth working group sessions (n = 10) identified needed modifications.

RESULTS

Adaptations to the curriculum and delivery modality were made to approximate the average length of stay in the shelter; integrate trauma-informed care approaches; increase diversity of images by race, ethnicity, age, sexual orientation, and gender identity; and increase the relevance of the audio-visual components.

CONCLUSIONS

Youth and the health and social services providers who care for youth generally liked the core concepts and presentation of the curriculum. Using the ADAPT-ITT framework, minor, yet important, changes were made to increase the relevance, acceptability, and feasibility of the intervention. Next steps are to conduct a randomized attention control pilot study to assess feasibility and acceptability.

Parent-reported provider recommendation of HPV vaccination among minority adolescents before and during the COVID-19 pandemic: Findings from the National Immunization Survey-Teen, 2019-2021

Provider recommendation of human papillomavirus (HPV) vaccination among adolescents has steadily improved over the years, however, limited research has been conducted to examine if the COVID-19 pandemic disrupted this positive trend in parent-reported provider recommendation among minority adolescents. Therefore, we conducted the present study to determine if there is an association between the pandemic and parent-reported provider recommendation of HPV vaccine among non-Hispanic black and Hispanic adolescents. We also examined whether any changes in parent-reported provider recommendation in the years 2019, 2020, and 2021 differed by race or ethnicity. Using a cross-sectional design to examine data from the National Immunization Survey-Teen (2019-2021), a moderation analysis and logistic regression analysis were performed to model race-specific variation in parent-reported provider recommendation (n = 50,739). We found that Hispanic parents had lower odds (aOR = 0.80 [0.71, 0.91]) of reporting receiving a recommendation compared to non-Hispanic white parents. We also found that the odds of parent-reported provider recommendation were higher in 2020 (aOR = 1.15 [1.03-1.29]) than in 2019. Other variables-age, region, sex, health insurance status, and poverty status-were all associated with parent-reported provider recommendation. These findings demonstrated that the pandemic may not have triggered any race-related gap in the recommendation of HPV vaccines, however, more pandemic-resilient public health efforts are needed to improve parent and provider communication regarding HPV vaccination of adolescents.

Observed and perceived benefits of providing physical activity opportunities in elementary schools: a qualitative study

Introduction

Schools play an important role in promoting physical activity for youth. However, school-based physical activity opportunities often compete with other academic priorities, limiting their implementation. The purpose of this study was to qualitatively explore elementary school teacher and staff perspectives on providing physical activity opportunities and how they impact students and learning.

Methods

We partnered with a school district in Texas to conduct semi-structured individual interviews. We used a purposeful sampling approach to recruit elementary teachers and staff knowledgeable about the physical activity opportunities provided at their school. Interviews included questions about participant opinions of providing physical activity opportunities and the types of opportunities provided. We analyzed data using a directed content analysis and iterative categorization approach.

Results

Fifteen participants (4 teachers, 4 physical education teachers, 3 assistant principals, and 4 principals) completed interviews from 10 elementary schools. Participants discussed observed and perceived benefits when providing physical activity opportunities, which emerged into four themes and subthemes: (1) academic benefits (learning readiness, learning engagement, and academic performance); (2) social-emotional benefits (behavior, interpersonal and social skills, and classroom culture); (3) physical benefits (brain health, skill development, physical health); and (4) instructional benefits (quality teaching time, helpful teaching tools, and teacher-student relationships).

Conclusions

Teachers and staff observed numerous benefits when students had opportunities to be physically active, including the positive impact on academic and social-emotional outcomes. Our findings highlight the alignment of physical activity with other school priorities. Physical activity programming can be used in ways to support academics, learning, behavior, and other important outcomes.

The prevalence of human papillomavirus vaccination among racial and ethnic minority adolescents during the COVID-19 pandemic

BACKGROUND

Human papillomavirus (HPV) vaccination among adolescents has steadily improved over the past several years. However, research conducted to determine whether the COVID-19 pandemic disrupted this positive trend in HPV vaccine initiation among racial and ethnic minority adolescents is limited. Therefore, this study was conducted to determine if the COVID-19 pandemic and the resulting changes in the US health-care sector affected the increasing HPV vaccine initiation among non-Hispanic Black and Hispanic adolescents aged 13-17 years.

METHODS

Using a cross-sectional design to examine data from the National Immunization Survey-Teen (2019-2021), logistic regression and moderation analysis were used to model race-specific variations in HPV vaccine initiation (n = 49 031). Two-sided P values of up to .05 were considered statistically significant.

RESULTS

Hispanic (adjusted odds ratio [AOR] = 1.35, 95% confidence interval [CI] = 1.16 to 1.57) and non-Hispanic Black (AOR = 1.29, 95% CI = 1.10 to 1.51) adolescents had higher odds of HPV vaccine initiation than did non-Hispanic White adolescents. Additionally, the odds of HPV vaccine initiation were higher in 2021 (AOR = 1.22, 95% CI = 1.08 to 1.38) than in 2019. Other variables-age, region, sex, insurance status, and poverty status-were also associated with HPV vaccine initiation.

CONCLUSION

These findings demonstrate that during the COVID-19 pandemic, racial and ethnic minorities had higher odds of receiving the HPV vaccine. Therefore, more research of the impact of the pandemic on HPV vaccine initiation among non-Hispanic White and racial and ethnic minority adolescents is needed.

Lessons Learned From Interdisciplinary Efforts to Combat COVID-19 Misinformation: Development of Agile Integrative Methods From Behavioral Science, Data Science, and Implementation Science

Background

Despite increasing awareness about and advances in addressing social media misinformation, the free flow of false COVID-19 information has continued, affecting individuals' preventive behaviors, including masking, testing, and vaccine uptake.

Objective

In this paper, we describe our multidisciplinary efforts with a specific focus on methods to (1) gather community needs, (2) develop interventions, and (3) conduct large-scale agile and rapid community assessments to examine and combat COVID-19 misinformation.

Methods

We used the Intervention Mapping framework to perform community needs assessment and develop theory-informed interventions. To supplement these rapid and responsive efforts through large-scale online social listening, we developed a novel methodological framework, comprising qualitative inquiry, computational methods, and quantitative network models to analyze publicly available social media data sets to model content-specific misinformation dynamics and guide content tailoring efforts. As part of community needs assessment, we conducted 11 semistructured interviews, 4 listening sessions, and 3 focus groups with community scientists. Further, we used our data repository with 416,927 COVID-19 social media posts to gather information diffusion patterns through digital channels.

Results

Our results from community needs assessment revealed the complex intertwining of personal, cultural, and social influences of misinformation on individual behaviors and engagement. Our social media interventions resulted in limited community engagement and indicated the need for consumer advocacy and influencer recruitment. The linking of theoretical constructs underlying health behaviors to COVID-19-related social media interactions through semantic and syntactic features using our computational models has revealed frequent interaction typologies in factual and misleading COVID-19 posts and indicated significant differences in network metrics such as degree. The performance of our deep learning classifiers was reasonable, with an F-measure of 0.80 for speech acts and 0.81 for behavior constructs.

Conclusions

Our study highlights the strengths of community-based field studies and emphasizes the utility of large-scale social media data sets in enabling rapid intervention tailoring to adapt grassroots community interventions to thwart misinformation seeding and spread among minority communities. Implications for consumer advocacy, data governance, and industry incentives are discussed for the sustainable role of social media solutions in public health.

Economic Evaluation of an Intervention to Prevent Adolescent Dating Violence (Me & You)

Me & You: Building Healthy Relationships (Me & You) is a multilevel, technology-enhanced adolescent dating violence (DV) prevention program that aimed to reduce DV among ethnic-minority, early adolescent, urban youth. A group-randomized control trial of Me & You, conducted with 10 middle schools from a large urban school district in Southeast Texas in 2014-2015, found it to be effective in reducing DV perpetration and decreasing some forms of DV victimization. Economic evaluations of DV interventions are extremely limited, despite calls for more economic analyses to be incorporated in research. We help fill this gap by evaluating the cost-effectiveness from the payer and societal perspectives of implementing the Me & You program. Using cost data collected alongside the Me & You group-randomized trial, we computed incremental cost-effectiveness ratios. Our primary outcome was "any DV perpetrated" within 12 months of the intervention. We conducted a cost-benefit analysis beyond the intervention endpoint by using literature estimates of per-victim lifetime costs of DV. We performed sensitivity analyses to assess effects of uncertain parameters. Under the base-case scenario, the cost of the Me & You curriculum compared to the standard curriculum was $103.70 per-student from the societal perspective, and the effectiveness was 34.84 perpetrations averted, implying an incremental cost per perpetration averted of $2.98, which ranged from $0.48 to $73.24 in sensitivity analysis. Thus, we find the Me & You curriculum is cost-effective and cost-saving in most scenarios. Policymakers should carefully consider school-based DV prevention programs, and cost data should be regularly collected in adolescent prevention program evaluations.

Digital Health Interventions to Improve Adolescent HPV Vaccination: A Systematic Review

Digital technologies are being increasingly utilized in healthcare to provide pertinent and timely information for primary prevention, such as vaccination. This study aimed to conduct a systematic review to describe and assess current digital health interventions to promote HPV vaccination among adolescents and parents of adolescents, and to recommend directions for future interventions of this kind. Using appropriate medical subject headings and keywords, we searched multiple databases to identify relevant studies published in English between 1 January 2017 and 31 July 2022. We screened and selected eligible studies for inclusion in the final analysis. We reviewed a total of 24 studies, which included interventions using text messages (4), mobile apps (4), social media and websites (8), digital games (4), and videos (4). The interventions generally improved determinants of HPV vaccination, such as HPV-related knowledge, vaccine-related conversations, and vaccination intentions. In particular, text message and social media interventions targeted improved vaccine uptake behaviors, but little meaningful change was observed. In conclusion, digital health interventions can cost-effectively provide education about HPV vaccination, offer interactive environments to alleviate parental vaccine hesitancy, and ultimately help adolescents engage in HPV vaccine uptake.

Maternal perceptions of vaccinating boys against human papillomavirus (HPV) in Seoul, South Korea: A descriptive exploratory qualitative study

Human Papillomavirus (HPV) vaccination is of paramount importance to reduce HPV-associated cancers in both genders. In South Korea, the prophylactic vaccine is recognized as prevention of cervical cancer with little attention given to male HPV vaccination. The purpose of this study was to explore perceptions of male HPV vaccination and underlying factors for vaccine hesitancy among mothers of unvaccinated boys in Seoul, Korea using a qualitative method. We used a purposive sampling strategy to recruit mothers of unvaccinated middle school-aged boys living in one of the 25 districts in Seoul, supplemented by a snowball sampling approach. We conducted one-on-one telephone interviews with ten mothers using a semi-structured interview guide. Questions probed mothers' views on vaccinating boys against HPV and the reasons for not vaccinating their sons. We found that mothers were hesitant to vaccinate their sons against HPV due to high out-of-pocket costs, fear of side effects concerning the young age of their sons, and low awareness of HPV and HPV vaccine, all of which stemmed from the exclusion of male HPV vaccination in the national immunization program. Sociocultural factors, including vaccination norms, lack of HPV education, and values associated with sexually transmitted infections were also likely to negatively impact mothers' vaccination decision-making. Despite the barriers, mothers were willing to accept HPV vaccination when it was framed as cancer prevention for not only the sons but also their future spouses. In conclusion, reasons for Korean mothers' hesitancy for their sons' HPV vaccine uptake were multifaceted. Healthcare providers' role in emphasizing and conveying the importance of gender-neutral HPV vaccination will be essential to alleviate negative sentiments around the vaccine for boys and reduce their risk of compromised sexual health. As an effective public health strategy, tailored cancer prevention messages should be delivered heightening significant benefits of the HPV vaccine beyond the prevention of cervical cancer.

Exploring Latino Perspectives in Childhood Fever: Beliefs, Practices, and Needs

INTRODUCTION

Latino parents have significant knowledge gaps and misconceptions about fever. In this study, we explored Latino beliefs and practices around fever and its impact on their care decisions.

METHODS

A qualitative-focused ethnography was conducted with 21 Latino parents. Semi-structured interviews were completed, and inductive thematic analysis was used to identify themes and subthemes.

RESULTS

Three major themes emerged: (a) the meaning of fever; (b) seeking guidance; and (c) navigating fever. Subthemes included: a sign of folk illness, a sign of infection, trust in health care providers, watchful waiting, and barriers and needs.

DISCUSSION

Latino parents have significant knowledge gaps about the role of fever in illness. They engage multiple systems of care but rarely share their fears with health care providers. Culturally-sensitive interventions incorporating traditional and biomedical approaches are needed. Findings can help inform future interventions targeting knowledge gaps in this population.

Adherence to the Recommended HPV Vaccine Dosing Schedule among Adolescents Aged 13 to 17 Years: Findings from the National Immunization Survey-Teen, 2019–2020

The 9-valent human papillomavirus (9-vHPV) vaccine uptake rate among adolescents has improved over the years; however, little is known about the adherence to the recommended dosing schedule. This study examines the prevalence and factors associated with adherence to the recommended 9vHPV vaccination dosing schedule among adolescents aged 13 to 17 years. The cross-sectional study was conducted using the 2019–2020 National Immunization Survey-Teen. The parents of 34,619 adolescents were included in our analyses. The overall up-to-date (UTD) prevalence was 57.1%. The UTD prevalence was 60.0% among females and 54.2% among males. Adolescents aged 16 years had the highest UTD prevalence of 63.0%. The UTD prevalence was 61.6% among Hispanics and 54.7% among non-Hispanic Whites. Overall, compared to females, males had 14% lower odds of UTD. The odds of UTD were 1.91 times, 2.08 times, and 1.98 times higher among adolescents aged 15–17 years, respectively, compared to those aged 13 years. Moreover, region, poverty, insurance status, mothers’ educational level, and provider recommendation were associated with UTD. Our findings show that adherence to the recommended 9vHPV vaccine schedule is low in the US. Targeted public health efforts are needed to improve the rates of adherence to the recommended 9vHPV dose schedule.

Using Community-Academic Partnerships and a Creative Expression Contest to Engage Youth in the Development of Communication Materials for Promoting Behaviors That Prevent COVID-19

Youth can transmit COVID-19 to adults, but few communication materials exist for engaging youth in COVID-19 prevention behaviors. We describe the process of leveraging a community-academic partnership in a rapid response initiative to engage youth in a contest (i.e., Youth-Led Creative Expression Contest to Prevent COVID-19 across Texas) to develop creative public health messaging centered on the prevention of COVID-19 transmission and infection for their peers. Core activities included developing a request for applications that solicited submission of creative expression materials promoting the use of COVID-19 prevention behaviors (mask-wearing, social distancing, handwashing, not touching the face) from Texas youth in elementary, middle, and/or high school; sending the request for applications to 48 organizations in Austin, Brownsville, Dallas, El Paso, Houston, and San Antonio in summer 2020; and recruiting a youth advisory board to score submissions and award prizes. We report on youth engagement in the COVID communication contest across Texas and use statistics (chi-square and t-tests) to characterize and compare youth participants and their creative expression artwork. The contest resulted in 3,003 website views and 34 submissions eligible for scoring. Each submission averaged >2 prevention behaviors. On average, winning submissions included a higher number of prevention behaviors than nonwinning submissions. The prevention behavior "not touching the face" was included more often in winning submissions than nonwinning submissions. Elementary school children were less likely to include a mask in their submission compared with older youth. Existing community-academic networks can engage youth in the development of geographically and age-tailored communication materials.

Adverse Childhood Experiences, Depression, Resilience, & Spirituality in African-American Adolescents

Research shows that exposure to adverse childhood experiences (ACEs) is common among adolescents and that exposure to ACEs is associated with an increased risk of depression in adolescents. Furthermore, it is unknown whether resilience and spirituality moderate the association between ACEs and depression in African-American adolescents. Thus, the present study examined the prevalence of ACEs and the association between ACEs and the risk for depression in African-American adolescents and examined whether this association is moderated by resilience and spirituality. Survey data were collected from African-American adolescents who attended youth-targeted events held by churches in Houston, TX. An expanded ACE tool was used to collect data and respondents were dichotomized into two groups based on their summed ACE scores, i.e., 0-3 ACEs versus 4-19 ACEs. Logistic regression was conducted to examine the association between ACEs and the likelihood of depression and to examine whether this association is moderated by resilience and spirituality. The results indicate that half of the sample had been exposed to four or more ACEs and that ACEs are negatively associated with depression: higher levels of resilience and spirituality suggest a lower likelihood of depression. These results suggest the need to explore the prevalence of cumulative ACEs among homogenous samples of African-American adolescents and the need to continue exploring and addressing the prevalence of individual ACEs among homogenous samples of African-American adolescents. No clinical trials were performed for this study.

Implementing an inpatient integrative medicine consult service for children with pain: A qualitative analysis

OBJECTIVES

Complementary and integrative medicine (CIM) therapies show clinical benefits with minimal side effects, yet challenges to effective integration in hospital settings remain. The current study aimed to better understand the process of integration of CIM therapies at a large urban pediatric hospital from the perspectives of providers, parents, and administrators.

DESIGN

The study employed an applied medical ethnography.

SETTING

The ethnography was conducted before, during, and after an Integrative Medicine Pain Consult Service (IM Pilot) was implemented at a large urban pediatric hospital during the spring of 2017.

MAIN OUTCOME MEASURES

Fieldwork interviews, participant observations, and document review captured aspects of the integration of CIM over a 6-month study period. Ethnographic analysis included thematic content analysis. Participants included providers (n = 10), administrators (n = 5), and parents of patients (n = 11).

RESULTS

Emergent themes from analysis of the interviews and field notes were organized according to the socio-ecological model. Themes included facilitating factors for CIM pain management at the intrapersonal and community levels (Alignment with Parental Perceptions of Child Needs and Provider Desire to Offer Care, Alignment of CIM with Spiritual Beliefs and Community Norms) and barriers at the interpersonal, organizational, and political levels (Inter-professional Challenges, Lack of Logistics in Place for Referrals and Triaging Patients with Pain, Lack of Remuneration/Insurance Reimbursement for Care).

CONCLUSIONS

To address barriers, future efforts to implement integrative pain management programs in pediatric hospital settings may consider testing implementation strategies, including engaging program champions and family advocates, providing education on CIM professions and therapies to hospital staff, and billing for provider time rather than individual CIM therapies.

School Staff's Perspectives on the Adoption of Elementary-School Physical Activity Approaches: A Qualitative Study

Background

There is a need to understand how schools adopt physical activity approaches (curricula, programs and practices), but few studies report on this process.

Purpose

To obtain elementary school staff's perspectives regarding how their schools are currently adopting physical activity approaches.

Methods

We recruited 15 participants from four job types in an urban Texas school district to participate in semi-structured interviews. We coded and analyzed interviews using directed content analysis and iterative categorization.

Results

We identified four themes pertaining to how the district, schools, and teachers contribute to the adoption of approaches. Themes included: (1) Staff identify new approaches through numerous channels; (2) Adoption occurs at multiple organizational levels; (3) District staff fulfilled a supporting role in the adoption process; and (4) School staff's perceptions of approach characteristics influence adoption.

Discussion

We found that schools adopt physical activity approaches at both the district- and school-level. Additionally, multiple stakeholders played a role in the adoption process and those roles varied across approaches.

Translation to Health Education Practice

Time, money, space, staff, competing priorities, limited information, the school's mission, and the benefits an approach provides to children are factors that researches and practitioners should consider when starting a new physical activity approach.

Qualitative process evaluation of a central line-associated bloodstream infection (CLABSI) prevention team in the neonatal intensive care unit

BACKGROUND

A central line-associated bloodstream infection (CLABSI) is a serious complication. Patients in the neonatal intensive care unit (NICU) are at increased risk for CLABSI, and hospitals often implement patient safety initiatives to prevent them. Studies have quantitatively demonstrated that line teams can reduce the rate of CLABSI. The purpose of this study was to qualitatively assess the function of the line team.

METHODS

Participants of the study were recruited from the NICU of a large children's hospital in Texas. Each participant provided oral consent to participate, and interviews were captured on audio recorder and transcribed. Thematic content analysis was used to evaluate the data.

RESULTS

We found that successful infection prevention requires collaborative work with all personnel in the NICU. We also found that line team personnel function as an extra level of support for bedside nurses, provide guidance on protocols, and serve as educators and trainers. Lastly, we heard several situations in which the essential function of the line team to prevent CLABSI is threatened by other necessary operations of the unit.

CONCLUSIONS

It is important for infection prevention initiatives to not only track and measure outcomes, but also consider the processes during implementation. This study provides important insight into the operation of the line team that should be contemplated by hospitals seeking to implement a similar initiative.

Mining HPV Vaccine Knowledge Structures of Young Adults From Reddit Using Distributional Semantics and Pathfinder Networks

The human papillomavirus (HPV) vaccine protects adolescents and young adults from 9 high-risk HPV virus types that cause 90% of cervical and anal cancers and 70% of oropharyngeal cancers. This study extends our previous research analyzing online content concerning the HPV vaccination in social media platforms used by young adults, in which we used Pathfinder network scaling and methods of distributional semantics to characterize differences in knowledge organization reflected in consumer- and expert-generated online content. The current study extends this approach to evaluate HPV vaccine perceptions among young adults who populate Reddit, a major social media platform. We derived Pathfinder networks from estimates of semantic relatedness obtained by learning word embeddings from Reddit posts and compared these to networks derived from human expert estimation of the relationship between key concepts. Results revealed that users of Reddit, predominantly comprising young adults in the vaccine catch up age-group 18 through 26 years of age, perceived the HPV vaccine domain from a virus-framed perspective that could impact their lifestyle choices and that their awareness of the HPV vaccine for cancer prevention is also lacking. Further differences in knowledge structures were elucidated, with implications for future health communication initiatives.

Employing Evidence in Evaluating Complementary Therapies: Findings from an Ethnography of Integrative Pain Management at a Large Urban Pediatric Hospital

BACKGROUND

Complementary and Integrative Medicine (CIM) shows positive clinical benefit with minimal side effects, yet, challenges to effective integration of CIM providers in biomedical health care settings remain. This study aimed to better understand the role evidence played in the process of integration of complementary therapies into a large urban pediatric hospital from the perspective of patients, caregivers, providers, and administrators through applied medical ethnography.

METHODS

An ethnography was conducted over the course of 6 months in a large urban pediatric hospital in the Southern United States. At the time, the hospital was piloting an integrative medicine (IM) pain consult service. Purposive sampling was used to select providers, patients, administrators, and caregivers to follow as they engaged with both the preexisting pain service and pilot IM pain services. Field observation and interviews were conducted with 34 participants. Thematic content analysis was used to analyze field notes, interview transcripts, and documents collected.

FINDINGS

Analysis of the data revealed five themes regarding the role of evidence in the process of integration: Anecdotal Evidence and Personal Experience Effecting CIM Use, Open to Trying Whatever Works, Resistance to the Unfamiliar, Patients and Parents Trusting Doctors as Experts, and Importance of Scientific Evidence to Biomedicine. All themes address the role of evidence in relationship to acceptance of complementary therapies and correspond with three thought processes: critical thinking, relying on others for evidence, and reactionary thinking.

CONCLUSION

Both scientific and anecdotal evidence informed CIM use in this context. Biomedical environments seeking to integrate CIM into pain treatment regimens will need to engage all relevant stakeholders in building education, clinical training, and research programs that are critically informed about the context and evidence for CIM.

Assessment of sexually transmitted disease/HIV risk among young African Americans: comparison of self-perceived and epidemiological risks utilizing ecodevelopmental theory

Background

Recent advances in understanding the developmental processes associated with adolescents warrant new thinking and systematic application of key concepts of risk and protective processes. This study examined the association between epidemiological and self-perceived risks of contracting sexually transmitted diseases (STDs)/HIV among young African Americans (AAs) and the multilevel factors identified using ecodevelopmental theory.

Methods

A retrospective cross-sectional study was conducted on wave 1 data from the National Longitudinal Study of Adolescent Health comprising 1,619 AA youth aged 14-18 years. Epidemiological and self-perceived HIV-risk indices were developed and their associations with ecodevelopmental system parameters evaluated.

Results

Significant discordance (P<0.0001) in the youths' self-perceived risk and epidemiological risk (the "gold standard") was recorded with Cohen's k-coefficient of 0.144 (95% CI 0.104-0.193). Adolescents who felt like talking to their mother had no trouble getting along with schoolteachers, perceived that teachers treated student fairly, experienced mother's disapproval of their sexual debut, and had close friends who knew how to use condoms correctly, were positively related to low epidemiological risk of contracting STDs/HIV. Being older, male, and a mother's positive attitude toward their adolescent's use of birth control (in exosystem) were associated with high epidemiological risk of contracting STDs/HIV. Furthermore, poor connection with the mother (did not feel like talking to mother) and growing older were related to low accuracy of self-risk perception among AA youths.

Conclusion

The findings demonstrate the strong need to align self-perceived risk with epidemiological risk of acquiring STDs/HIV using the key multilevel ecodevelopmental system factors identified. This will require changes in relevant social attitudes and norms associated with risk measurement, and allow for a rational basis for safe health practices and behaviors among AA youths.

Evaluating centralized technical assistance as an implementation strategy to improve cancer prevention and control

PURPOSE

In 2015-2016, the Comprehensive Cancer Control National Partnership provided technical assistance workshops to support 22 cancer coalitions in increasing human papillomavirus (HPV) vaccination uptake and increasing colorectal cancer (CRC) screening in their local communities. As national efforts continue to invest in providing technical assistance, there is a current gap in understanding its use as a strategy to accelerate implementation of evidence-based interventions (EBIs) for cancer prevention. The objective of this study was to evaluate the impact of technical assistance on the participants' knowledge, attitudes, and skills for implementing EBIs in their local context and enhancing state team collaboration.

METHODS

Data were collected August-November 2017 using web-based questionnaires from 44 HPV workshop participants and 66 CRC workshop participants.

RESULTS

Both HPV vaccination and CRC screening workshop participants reported changes in knowledge, attitudes, and skills related to implementing EBIs in their local state context. Several participants reported increased abilities in communicating and coordinating with partners in their states and utilizing additional implementation strategies to increase HPV vaccination uptake and CRC screening rates.

CONCLUSIONS

Findings from this study suggest that providing technical assistance to members of comprehensive cancer control coalitions is useful in promoting collaborations and building capacity for implementing EBIs for cancer prevention and control.

HIV-related sexual decisions made by African-American adolescents living in different family structures: study from an ecodevelopmental perspective

PURPOSE

The purpose of this study was to explore the association between the dynamics of family structure and sexual behaviors of African-American adolescents using the ecodevelopmental theory.

METHODS

This study stratified data from 1,617 African-American adolescents of the Add Health Wave I respondents with an identified family composition. It examined the associations between family structure, parenting function, and adolescents' sexual decision-making: age of first sexual intercourse, sexual initiation before age 16, and using a condom during the first and last sexual intercourse.

RESULTS

Emotional connection between parents and children (feeling more love from the father: β=0.17, P=0.0312; feeling more love from the mother: β=0.3314, P=0.0420) and mothers' less permissive attitude toward adolescents' sexual experience in their teens (β=0.33, P=0.0466) are positively associated with late age of sexual initiation of adolescents living in two-parent households. School-level factors (β=0.07, P=0.0008) and the adolescents' characteristics (being older: 0.42, P=0.0002; heterosexuality: β=2.28, P=0.0091) are the factors most positively related to the age of sexual initiation for those living with a single parent. Immediate social determinants, other than family factors (such as land use of immediate area [rural]: β=9.84, P<0.0001; the condition of living unit: β=1.55, P=0.0011; and safety of neighborhood: β=4.46, P=0.004), are related to late age of sexual initiation among those living with other relatives/alone. A higher tendency of condom use consistency was present in adolescents living with two parents compared to those living in other family structures.

CONCLUSION

Less parent/child connection and parent/family influence were found in African-American adolescents living with other relatives or alone, suggesting that living with two residential parents plays an essential role in their late sexual initiation and could account for an important element to combat high HIV incidence of African-American adolescents.

Using Intervention Mapping for Program Design and Production of iCHAMPSS: An Online Decision Support System to Increase Adoption, Implementation, and Maintenance of Evidence-Based Sexual Health Programs

In Texas and across the United States, unintended pregnancy, HIV, and sexually transmitted infections (STIs) among adolescents remain serious public health issues. Sexual risk-taking behaviors, including early sexual initiation, contribute to these public health problems. Over 35 sexual health evidence-based programs (EBPs) have been shown to reduce sexual risk behaviors and/or prevent teen pregnancies or STIs. Because more than half of these EBPs are designed for schools, they could reach and impact a considerable number of adolescents if implemented in these settings. Most schools across the U.S. and in Texas, however, do not implement these programs. U.S. school districts face many barriers to the successful dissemination (i.e., adoption, implementation, and maintenance) of sexual health EBPs, including lack of knowledge about EBPs and where to find them, perceived lack of support from school administrators and parents, lack of guidance regarding the adoption process, competing priorities, and lack of specialized training on sexual health. Therefore, this paper describes how we used intervention mapping (Steps 3 and 4, in particular), a systematic design framework that uses theory, empirical evidence, and input from the community to develop CHoosing And Maintaining Effective Programs for Sex Education in Schools (iCHAMPSS), an online decision support system to help school districts adopt, implement, and maintain sexual health EBPs. Guided by this systematic intervention design approach, iCHAMPSS has the potential to increase dissemination of sexual health EBPs in school settings.

Modeling ecodevelopmental context of sexually transmitted disease/HIV risk and protective behaviors among African-American adolescents

Risk and protective processes are integrated developmental processes that directly or indirectly affect behavioral outcomes. A better understanding of these processes is needed, in order to gauge their contribution to sexual risk behaviors. This retrospective cross-sectional study modeled the ecodevelopmental chain of relationships to examine the social contexts of African-American (AA) adolescents associated with sexually transmitted disease (STD)- and HIV-risk behaviors. We used data from 1,619 AA adolescents with an average age of 16±1.8 years obtained from the first wave of the National Longitudinal Study of Adolescent Health for this study. Confirmatory factor analysis followed by structural equation modeling was conducted to identify the latent constructs that reflect the social-interactional components of the ecodevelopmental theory. Among contextual factors, findings indicated that a feeling of love from father, school, religion, and parent attitudes toward adolescent sexual behavior were all factors that played significant roles in the sexual behavior of AA adolescents. AA adolescents who reported feeling love from their father, feeling a strong negative attitude from their parents toward having sex at a very young age, and having a strong bond with school personnel were associated with better health statuses. The level of parents' involvement in their children's lives was reflected in the adolescents' feeling of love from parents and moderated by their socioeconomic status. Being male, attaining increased age, and being a sexual minority were associated with higher likelihood of exhibiting risky sexual behavior. In contrast, higher socioeconomic status and fathers' level of involvement were indirectly associated with reduced STD/HIV-related sexual risk behavior. In conclusion, our findings suggest that interventions aimed at maximal protection against STD/HIV-related risk behavior among AA adolescents should adopt both self- and context-based strategies that promote positive functioning in the family, school, and peer microsystems.

Perceived Physical Appearance: Assessing Measurement Equivalence in Black, Latino, and White Adolescents

Objective

This aim of this study was to examine whether the construct of physical appearance perception differed among the three largest racial/ethnic groups in the United States using an adolescent sample.

Methods

Black (46%), Latino (31%), and White (23%) adolescents in Grade 10 from the Healthy Passages study ( N  = 4,005) completed the Harter's Self-Perception Profile for Adolescents-Physical Appearance Scale (SPPA-PA) as a measure of physical appearance perception.

Results

Overall, Black adolescents had a more positive self-perception of their physical appearance than Latino and White adolescents. However, further analysis using measurement invariance testing revealed that the construct of physical appearance perception, as measured by SPPA-PA, was not comparable across the three racial/ethnic groups in both males and females.

Conclusions

These results suggest that observed differences may not reflect true differences in perceptions of physical appearance. Measures that are equivalent across racial/ethnic groups should be developed to ensure more precise measurement and understanding.

Implementing an ICT-Based Polypharmacy Management Program in Italy

Although there is evidence of a growing awareness of the problem, no official policy statements or regulatory guidelines on polypharmacy have been released up to date by Italian Health Authorities. Medication review, application of appropriateness criteria and computerized prescription support systems are all possible approaches in order to improve the quality of prescribing in older persons. More focused training courses on multimorbidity and polytherapy management are encouraged. Furthermore a multidisciplinary approach integrating different health care professionals (physicians, pharmacists, and nurses) may positively impact on reducing the sense of fear related to discontinue or substitute drugs prescribed by others; the fragmentation of therapy among different specialists; reducing costs; and improving adverse drug reaction detection and reporting. Aiming at achieving the individualized pharmacotherapy, a multidisciplinary approach starting with identification of patients and risk for drug-related problems, followed by medication review overtime and use of inappropriateness criteria, supported by computerized systems has been proposed.

Racial and Ethnic Disparities in ADHD Diagnosis and Treatment

OBJECTIVES

We examined racial/ethnic disparities in attention-deficit/hyperactivity disorder (ADHD) diagnosis and medication use and determined whether medication disparities were more likely due to underdiagnosis or undertreatment of African-American and Latino children, or overdiagnosis or overtreatment of white children.

METHODS

We used a population-based, multisite sample of 4297 children and parents surveyed over 3 waves (fifth, seventh, and 10th grades). Multivariate logistic regression examined disparities in parent-reported ADHD diagnosis and medication use in the following analyses: (1) using the total sample; (2) limited to children with an ADHD diagnosis or symptoms; and (3) limited to children without a diagnosis or symptoms.

RESULTS

Across all waves, African-American and Latino children, compared with white children, had lower odds of having an ADHD diagnosis and of taking ADHD medication, controlling for sociodemographics, ADHD symptoms, and other potential comorbid mental health symptoms. Among children with an ADHD diagnosis or symptoms, African-American children had lower odds of medication use at fifth, seventh, and 10th grades, and Latino children had lower odds at fifth and 10th grades. Among children who had neither ADHD symptoms nor ADHD diagnosis by fifth grade (and thus would not likely meet ADHD diagnostic criteria at any age), medication use did not vary by race/ethnicity in adjusted analysis.

CONCLUSIONS

Racial/ethnic disparities in parent-reported medication use for ADHD are robust, persisting from fifth grade to 10th grade. These findings suggest that disparities may be more likely related to underdiagnosis and undertreatment of African-American and Latino children as opposed to overdiagnosis or overtreatment of white children.

The association between youth violence exposure and attention-deficit/hyperactivity disorder (ADHD) symptoms in a sample of fifth-graders

The purpose of the current study was to examine the association between violence exposures (no exposure, witness or victim only, and both witness and victim) and attention-deficit/hyperactivity disorder (ADHD) symptoms, as well as the potential moderating role of gender. Data from 4,745 5th graders and their primary caregivers were drawn from the Healthy Passages study of adolescent health. Parent respondents completed the DISC Predictive Scales for ADHD, and youth provided information about exposure to violence. Results indicated that youth who reported both witnessing and victimization had more parent-reported ADHD symptoms and were more likely to meet predictive criteria for ADHD. Among those with both exposures, girls exhibited a steeper increase in ADHD symptoms and higher probability of meeting predictive criteria than did boys. Findings indicate that being both victim-of and witness-to violence is significantly associated with ADHD symptoms particularly among girls.

Regular physical activity has differential association with reduced obesity among diverse youth in the United States

This study examined whether daily or almost daily lower-intensity physical activity was associated with reduced obesity, among 4824 African American, Hispanic, and White youth assessed in fifth and seventh grades. Regular lower-intensity physical activity was associated with reduced obesity only among Hispanic and White males and only in seventh grade, and not among youth in fifth grade, females, or African American males or females. Findings from this study suggest that the reduced obesity risk generally attributed to physical activity may not be consistent across racial/ethnic and gender groups of early adolescents.

Changes in obesity between fifth and tenth grades: a longitudinal study in three metropolitan areas

BACKGROUND

Despite epidemic childhood obesity levels, we know little about how BMI changes from preadolescence to adolescence and what factors influence changes.

METHODS

We studied 3961 randomly selected public school students and 1 parent per student in 3 US metropolitan areas in fifth and again in tenth grades. In each grade, we measured child and parent height/weight and calculated BMI category. We examined whether baseline sociodemographic characteristics, child health-related factors, and parental obesity were significantly associated with exit from and entry into obesity from fifth to tenth grade.

RESULTS

Fifth- and tenth-graders were 1%/2% underweight, 53%/60% normal weight, 19%/18% overweight, and 26%/20% obese, respectively. Among obese tenth-graders, 83% had been obese as fifth-graders and 13% had been overweight. Sixty-five percent of obese fifth-graders remained obese as tenth-graders, and 23% transitioned to overweight. Multivariately, obese fifth-graders who perceived themselves to be much heavier than ideal (P = .01) and those who had lower household education (P = .006) were less likely to exit obesity; by contrast, overweight fifth-graders were more likely to become obese if they had an obese parent (P < .001) or watched more television (P = .02).

CONCLUSIONS

Obese fifth-graders face challenges in reducing obesity, especially when they lack advantages associated with higher socioeconomic status or when they have a negative body image. Clinicians and others should educate parents on the importance of preventing obesity very early in development. Children who are not yet obese by fifth grade but who have an obese parent or who watch considerable television might benefit from monitoring, as might children who have negative body images.

Associations between socioeconomic status and obesity in diverse, young adolescents: variation across race/ethnicity and gender

OBJECTIVE

This study examined the association between socioeconomic status (SES) and obesity risk during early adolescence, ages 10-13 years, and whether this association is present in different racial/ethnic and gender groups during 2 time points in early adolescence.

METHOD

Data were from the Healthy Passages study, which enrolled 4,824 African American, Hispanic, and White 5th graders (ages 10-11) in a population-based, longitudinal study conducted in 3 U.S. metropolitan areas, and assessed them again 2 years later. Weight status was classified from measured body mass index using standard criteria into nonobese and obese (27% in 5th grade). SES was indexed based on highest education attainment in the household.

RESULTS

Youth in the highest SES had a significantly lower prevalence of obesity than those of lower SES at both 5th and 7th grades when disregarding race/ethnicity. Within-racial/ethnic group analyses mostly confirmed this pattern for Hispanic and White youth, but not for African American youth. When also considering gender, the SES differential in obesity risk was more pronounced among White girls and 5th-grade Hispanic boys.

CONCLUSION

Growing up in a high SES home, marked by having a member with at least a college degree, is associated with lower risk for obesity among Hispanic and White youth. For African American youth, there appears to be no association between SES and obesity. Thus the health advantage generally attributed to higher SES does not appear consistently across racial/ethnic groups for obesity in youth. Further research should identify influences on weight status beyond SES, especially among African American youth.

Early puberty, negative peer influence, and problem behaviors in adolescent girls

OBJECTIVE

To determine how early puberty and peer deviance relate to trajectories of aggressive and delinquent behavior in early adolescence and whether these relationships differ by race/ethnicity.

METHODS

In this longitudinal study, 2607 girls from 3 metropolitan areas and their parents were interviewed at ages 11, 13, and 16 years. Girls reported on their age of onset of menarche, best friend's deviant behavior, delinquency, and physical, relational, and nonphysical aggression. Parents provided information on family sociodemographic characteristics and girls' race/ethnicity.

RESULTS

Sixteen percent of girls were classified as early maturers (defined by onset of menarche before age 11 years). Overall, relational and nonphysical aggression increased from age 11 to age 16, whereas delinquency and physical aggression remained stable. Early puberty was associated with elevated delinquency and physical aggression at age 11. The relationship with early puberty diminished over time for physical aggression but not for delinquency. Best friend's deviant behavior was linked with higher levels of all problem behaviors, but the effect lessened over time for most outcomes. Early puberty was associated with a stronger link between best friend's deviance and delinquency, suggesting increased vulnerability to negative peer influences among early-maturing girls. A similar vulnerability was observed for relational and nonphysical aggression among girls in the "other" racial/ethnic minority group only.

CONCLUSIONS

Early puberty and friends' deviance may increase the risk of problem behavior in young adolescent girls. Although many of these associations dissipate over time, early-maturing girls are at risk of persistently higher delinquency and stronger negative peer influences.

It's Your Game…Keep It Real: can innovative public health prevention research thrive within a comparative effectiveness research framework?

The federal comparative effectiveness research (CER) initiative is designed to evaluate best practices in health care settings where they can be disseminated for immediate benefit to patients. The CER strategic framework comprises four categories (research, human and scientific capital, data infrastructure, and dissemination) with three crosscutting themes (conditions, patient populations, and types of intervention). The challenge for the field of public health has been accommodating the CER framework within prevention research. Applying a medicine-based, research-to-practice CER approach to public health prevention research has raised concerns regarding definitions of acceptable evidence (an evidence challenge), effective intervention dissemination within heterogeneous communities (a dissemination and implementation challenge), and rewards for best practice at the cost of other promising but high-risk approaches (an innovation challenge). Herein, a dynamic operationalization of the CER framework is described that is compatible with the development, evaluation, and dissemination of innovative public health prevention interventions. An effective HIV, STI, and pregnancy prevention program, It's Your Game…Keep It Real, provides a case study of this application, providing support that the CER framework can compatibly coexist with innovative, community-based public health prevention research.

Unmet eye care needs among U.S. 5th-grade students

BACKGROUND

There is substantial evidence of a disparity in access to eye care services among adults in the U.S.; however, little is known about health disparities for children's eye care.

PURPOSE

The goal of the study was to assess the prevalence of and risk factors for 5th-grade students' unmet eye care needs.

METHODS

Data were collected from 5147 5th-grade students (aged 10-11 years) and their parents and primary caregivers (hereafter "parents") participating in the Healthy Passages study between fall 2004 and summer 2006 (analyzed in 2011). Logistic regression estimated the probability of inability to afford needed eyeglasses and absence of vision insurance coverage.

RESULTS

1794 5th-grade students wore eyeglasses or were told that they need eyeglasses; 13.7% of their parents were unable to afford needed eyeglasses (new prescription or replacement) for their children; 27.4% of their parents reported no vision insurance coverage for eye examinations and eyeglasses. After controlling for confounders, parents without general children's health insurance were more likely to report being unable to afford eyeglasses than those with health insurance (Medicaid, SCHIP, private/other insurance; adjusted percentages: 22.5% vs 10.9%, 9.6%, 12.5%; all p<0.05). Parents with lower income were more likely to report being unable to afford children's eyeglasses even after controlling for all other factors (17.6% with income <$15,000 vs 2.7% with income ≥$70,000; p<0.001).

CONCLUSIONS

SES and health insurance status are strongly associated with 5th-grade students' unmet eye care needs. Policies targeting socioeconomically disadvantaged groups and those without insurance may be needed to reduce disparities in access to appropriate eye care.

Social competence in late elementary school: relationships to parenting and neighborhood context

Despite evidence that neighborhoods confer both risk and resilience for youth development, the existing neighborhood research has a number of methodological limitations including lack of diversity in neighborhoods sampled and neighborhood characteristics assessed. The purpose of this study was to address these methodological limitations of existing research and to examine the relationship of neighborhood structural and social characteristics to family-level social processes and teacher-reported social competence during early adolescence. The study sample of 3,624 fifth graders (51 % girls) was ethnically diverse, including roughly even proportions of non-Hispanic White, non-Hispanic Black, and Hispanic youth. Neighborhood measures included economic disadvantage derived from the U.S. Census, physical and social disorder obtained by direct observation, and social capital from parental reports. Family-level social processes included parent reported family cohesion and youth reported maternal and paternal nurturance. We found that neighborhood factors significantly associated with youth social aggression and social competence but not social withdrawal, after controlling for individual demographic characteristics and parenting factors. There was limited evidence of moderation of family influences by neighborhood characteristics as well as the moderation of neighborhood effects by children's gender. Neighborhood physical disorder was associated with increased social aggression among boys but with increased social withdrawal among girls. Implications of the study's findings for research on neighborhoods and adolescent development and the development of preventive interventions are discussed.

Association of family stressful life-change events and health-related quality of life in fifth-grade children

OBJECTIVE

To examine the association of recent family-related stressful life-change events (SLEs) with health-related quality of life (HRQOL) in fifth graders.

DESIGN

Population-based, cross-sectional survey.

SETTING

Three US metropolitan areas; 2004-2006.

PARTICIPANTS

A total of 5147 fifth graders and their parents.

MAIN EXPOSURES

Nine recent family-related SLEs: a parent's death, another family member's death, a family member's injury/illness, a family member's alcohol/drug problems, loss of a pet, recent change of residence, addition of a new baby or child to the household, parental separation, and parental divorce.

MAIN OUTCOME MEASURE

The HRQOL measured using the 23-item Pediatric Quality of Life Inventory.

RESULTS

Twenty-four percent of children had no reported recent SLEs; 33% had 1, 25% had 2, 12% had 3, and 6% had 4 or more. Mean HRQOL scores (total, physical, and psychosocial scales) were lower for children with more SLEs. The mean total HRQOL score was 80.4 (95% confidence interval, 79.4-81.3) for children with no recent SLEs and 71.8 (70.2-73.5) for children with 4 or more SLEs (P < .001). In adjusted logistic regression analyses, children with more SLEs had greater odds of impaired HRQOL compared with children without any SLEs. Psychosocial HRQOL fully mediated the relationship between SLEs and physical HRQOL.

CONCLUSIONS

The occurrence of multiple family-related SLEs in children is associated with less positive HRQOL. By incorporating the needs of families as part of comprehensive, high-quality care, health care professionals can identify these types of family-level needs and assist families in accessing community resources for support.

Neighborhood characteristics favorable to outdoor physical activity: disparities by socioeconomic and racial/ethnic composition

This paper uses a socioecological framework to investigate socioeconomic and racial/ethnic disparities in neighborhood characteristics that are associated with outdoor physical activity. We surveyed 632 parents of 5th graders about perceptions of their neighborhood social processes and collected systematic observations of the physical environment on their block-face of residence. Higher poverty neighborhoods and non-White neighborhoods have better accessibility; however, they are less safe, less comfortable, and less pleasurable for outdoor physical activity, and have less favorable social processes. Interventions to reduce disparities in physical activity should address not only the physical environment, but also social processes favorable to physical activity.

Prevalence, characteristics, and associated health and health care of family homelessness among fifth-grade students

OBJECTIVES

We describe the lifetime prevalence and associated health-related concerns of family homelessness among fifth-grade students.

METHODS

We used a population-based, cross-sectional survey of 5147 fifth-grade students in 3 US cities to analyze parent-reported measures of family homelessness, child health status, health care access and use, and emotional, developmental, and behavioral health and child-reported measures of health-related quality of life and exposure to violence.

RESULTS

Seven percent of parents reported that they and their child had experienced homelessness (i.e., staying in shelters, cars, or on the street). Black children and children in the poorest families had the highest prevalence of homelessness (11%). In adjusted analyses, most general health measures were similar for children who had and had not been homeless. Children who had ever experienced homelessness were more likely to have an emotional, behavioral, or developmental problem (odds ratio [OR] = 1.7; 95% confidence interval [CI] = 1.1, 2.6; P = .01), to have received mental health care (OR = 2.2; 95% CI = 1.6, 3.2; P < .001), and to have witnessed serious violence with a knife (OR = 1.6; 95% CI = 1.1, 2.3; P = .007) than were children who were never homeless.

CONCLUSIONS

Family homelessness affects a substantial minority of fifth-grade children and may have an impact on their emotional, developmental, and behavioral health.

Influences of physical and social neighborhood environments on children's physical activity and obesity

OBJECTIVES

We investigated the association between physical and social neighborhood environments and fifth-grade students' physical activity and obesity.

METHODS

We collected data on 650 children and their primary caregivers during phase 1 of Healthy Passages, a multisite, community-based, cross-sectional study of health risk behaviors and health outcomes in children. We conducted independent systematic neighborhood observations to measure neighborhood physical characteristics, and we analyzed survey data on social processes. We modeled children's physical activity and obesity status with structural equation models that included latent variables for the physical and social environments.

RESULTS

After we controlled for children's sociodemographic factors, we found that a favorable social environment was positively associated with several measures of physical activity and that physical activity was negatively associated with obesity in these children. Physical environment was not significantly associated with physical activity.

CONCLUSIONS

Our findings suggest that neighborhood social factors as well as the physical environment should be considered in the development of health policy and interventions to reduce childhood obesity.

Racial/Ethnic disparities in the mental health care utilization of fifth grade children

OBJECTIVE

The aim of this study was to examine racial/ethnic differences in fifth grade children's mental health care utilization.

METHODS

We analyzed cross-sectional data from a study of 5147 fifth graders and their parents in 3 US metropolitan areas from 2004-06. Multivariate logistic regression was used to examine racial/ethnic differences in mental health care utilization.

RESULTS

Nine percent of parents reported that their child had ever used mental health care services; fewer black (6%) and Hispanic (8%) children had used services than white children (14%). Fewer black and Hispanic children with recent symptoms of attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder, and fewer black children with symptoms of depression had ever utilized services compared with white children. In multivariate analyses controlling for demographic factors, parental mental health, social support, and symptoms of the 4 mental health conditions, we found that black children were less likely than white children to have ever used services (Odds ratio [OR] 0.3, 95% confidence interval [95% CI], 0.2-0.4, P < .001). The odds ratio for black children remained virtually unchanged when the analysis was restricted to children with symptoms of >/=1 mental health condition, and when the analysis was stratified by mental health condition. The difference in utilization for Hispanic compared with white children was fully explained by sociodemographics in all multivariate models.

CONCLUSIONS

Disparities exist in mental health care utilization for black and Hispanic children; the disparity for black children is independent of sociodemographics and child mental health need. Efforts to reduce this disparity may benefit from addressing not only access and diagnosis issues, but also parents' help-seeking preferences for mental health care for their children.

Positive parenting and early puberty in girls: protective effects against aggressive behavior

OBJECTIVE

To determine whether positive parenting practices are associated with less aggressive and delinquent behavior in early-maturing girls.

DESIGN

Cross-sectional survey.

SETTING

Interviews with a community sample of children and their caregivers were conducted in their homes or in a research setting.

PARTICIPANTS

An ethnically diverse cohort of 330 fifth-grade girls (mean age, 11.25 years) from 3 metropolitan areas.

MAIN EXPOSURE

Early onset of menarche, parental nurturance, knowledge of the child's activities, and communication.

MAIN OUTCOME MEASURES

Physical, relational, and nonphysical aggression and delinquent behavior.

RESULTS

A total of 25% of girls could be reliably classified as early maturers. Early maturation was associated with delinquency (b = 0.53) but not aggression. Low levels of maternal nurturance were associated with delinquency and relational aggression (both b = -0.04). Early maturation was associated with higher relational aggression only at low levels of nurturance (b = 0.94), communication (b = 1.36), and knowledge (b = 1.06) (P < .05 for each interaction). Also, early maturation only predicted physical aggression when combined with low maternal nurturance (b = 0.93).

CONCLUSIONS

Early puberty is a risk factor for delinquency, and early puberty combined with low parental nurturance, communication, or parental knowledge of the child's activities presents a risk for aggressive behavior in early adolescent girls. Early-maturing girls may benefit from increased parental nurturance, communication, and knowledge.

[CUA analysis in new drug evaluation: a review of available tools]

Cost utility analysis (CUA) is a peculiar kind of efficacy evaluation. The outcome is the quality adjusted years of life derived by comparing an intervention versus a comparator. We review literature analyzing some criticism emerging from Cost Utility evaluation as selection bias or eventual methodological inconsistency. We applied this model to a new drug--Macugen--assessing an incremental cost of 7258.68 euro for a two years treatment schedule. Our analysis suggest that CUA is potential informative especially in certain context as prevention, but efficacy assessment and robust outcomes measuring is crucial.