Do Children with Special Health Care Needs with Anxiety have Unmet Health Care Needs? An Analysis of a National Survey Abstract Objective To describe differences in health care needs between Children with Special Health Care Needs (CSHCN) with and without anxiety and examine the association between anxiety and unmet health care needs. Methods We analyzed data from the 2009/2010 national survey of CSHCN. The independent variable was anxiety. The main outcomes were health care needs and unmet needs. Covariates included demographics, other co-morbid conditions, and the presence and quality of a medical home. We used bivariate analyses and multivariable logistic regression to assess the relationships among anxiety, covariates, and the outcomes. We stratified our analysis by age (6–11 years, 12–17 years). Propensity score matched paired analysis was used as a sensitivity analysis. Results Our final sample included 14,713 6–11 year-olds and 15,842 12–17-year-olds. Anxiety was present in 16% of 6–11 year-olds and 23% or 12–17 year-olds. In bivariate analyses, CSHCN with anxiety had increased health care needs and unmet needs, compared to CSHCN without anxiety. In multivariable analyses, only children 12–17 years old with anxiety had increased odds of having an unmet health care need compared to those children without anxiety (OR 1.44 [95% CI 1.17–1.78]). This was confirmed in the propensity score matching analysis (OR 1.12, [95% CI 1.02–1.22]). The specific unmet needs for older CSHCN with anxiety were mental health care (OR 1.54 [95% CI 1.09–2.17]) and well child checkups (OR 2.01 [95% CI 1.18–3.44]). Conclusion Better integration of the care for mental and physical health is needed to ensure CSHCN with anxiety have all of their health care needs met.

Key Population Health Outcomes for Children with Medical Complexity: A Systematic Review Abstract Introduction Despite the significant healthcare policy and program implications, a summary measure of health for children with medical complexity (CMC) has not been identified. It is unclear whether existing population health approaches apply to CMC. We conducted a systematic review of the existing peer-reviewed research literature on CMC to describe the health outcomes currently measured for CMC. Methods We searched MEDLINE and PsycINFO by linking combinations of key words from three groups of concepts: (1) pediatric, (2) medical complexity, and (3) chronicity or severity. Study eligibility criteria were research studies including CMC with any outcome reported. Data on the outcomes were systematically extracted. Iterative content analysis organized outcomes into conceptual domains and sub-domains. Results Our search yielded 3853 articles. After exclusion criteria were applied, 517 articles remained for data extraction. Five distinct outcome domains and twenty-four sub-domains emerged. Specifically, 50% of the articles studied healthcare access and use; 43% family well-being; 39% child health and well-being; 38% healthcare quality; and 25% adaptive functioning. Notably lacking were articles examining routine child health promotion as well as child mental health and outcomes related to family functioning. Conclusions Key health domains for CMC exist. Adaptations of existing sets of metrics and additional tools are needed to fully represent and measure population health for CMC. This approach may guide policies and programs to improve care for CMC.

Acceptability of Interventions to Improve Engagement in HIV Care Among Pregnant and Postpartum Women at Two Urban Clinics in South Africa Abstract Introduction Pregnant women initiating antiretroviral therapy (ART) in sub-Saharan Africa have been shown to have sub-optimal engagement in care, particularly after delivery, and interventions to improve engagement in care for this unique population are urgently needed. Methods We enrolled 25 pregnant women living with HIV at each of two large antenatal clinics in Johannesburg and Cape Town, South Africa (n = 50), and conducted in-depth interviews. We assessed participants’ reported acceptability of the following proposed interventions to improve engagement in care and retention monitoring data systems: financial incentives, educational toys, health education, combined maternal/infant visits, cell phone text reminders, mobility tracking, fingerprint/biometric devices, and smartcards. Results Acceptability overall for interventions was high, with mixed responses for some interventions. Overall themes identified included (i) the intersection of individual and facility responsibility for a patient’s health, (ii) a call for more health education, (iii) issues of disclosure and concerns about privacy, and (iv) openness to interventions that could improve health systems. Discussion These findings provide insight into the preferences and concerns of potential users of interventions to improve engagement in HIV care for pregnant women, and support the development of tools that specifically target this high-risk group.

Neighborhood Context and the Risk for Developmental Disabilities in Early Childhood Abstract The effects of place on human health and development have been extensively studied in recent years in the adult and adolescent populations, but minimal research has addressed neighborhood effects in early childhood. This analysis of the National Survey of Children’s Health 2011/2012 cross-sectional survey examined relationships between risk for developmental disability in early childhood and neighborhood characteristics in a nationally-representative sample of children ages 0–5 years. Parents reported on their child’s development using a well-validated parent report screening tool for developmental problems (the Parent’s Evaluation of Developmental Status tool), and neighborhood and family characteristics. Multinomial logistic regression analyses were conducted for each of three neighborhood variables: physical disorder, safety, and isolation. After controlling for parental and child characteristics, the three neighborhood variables were each significantly associated with moderate (but not severe) risk versus low to no risk for developmental disabilities. When all neighborhood characteristics were included simultaneously in the same model, only physical disorder remained statistically significant [OR 1.44 (95% CI 1.09–1.91)], though modestly attenuated. These results suggest that neighborhoods may have effects on early childhood development, after controlling for individual child, parental, and family characteristics.

Effect of Infant Iron Deficiency on Children’s Verbal Abilities: The Roles of Child Affect and Parent Unresponsiveness Abstract Background Infants who are iron-deficient anemic seek and receive less stimulation from their caregivers, predisposing such children to be functionally isolated. Objectives To test the sequence whereby iron deficiency in infancy contributes to children’s disengagement from the environment, which reduces parent stimulation which, in turn, contributes to children’s poor verbal skills. Methods Chilean children (N = 875, 54% male) were studied, 45% of whom were iron deficient or iron-deficient anemic in infancy. We used structural equation modeling to test the sequence outlined above and to examine the effect of infant iron status on children’s verbal performance at ages 5 and 10 years including the roles of child and parent intermediate variables. Results Severity of iron deficiency in infancy was associated with higher levels of children’s dull affect and social reticence at 5 years (β = .10, B = .26, SE = .12, p < .05), and these behaviors were associated with parent unresponsiveness (β = .29, B = .13, SE = .03, p < .001), which related to children’s lower verbal abilities at age 5 (β = − .29, B = − 2.33, SE = .47, p < .001) and age 10 (β = − .22, B = − 3.04, SE = .75, p < .001). An alternate model where poor iron status related directly to children’s verbal ability was tested but not supported. Conclusions Findings support functional isolation processes resulting from a nutritional deficiency, with iron-deficient anemic infants showing affective and behavioral tendencies that limit developmentally stimulating caregiving which, in turn, hinder children’s verbal abilities.

On the Stability of Reported Pregnancy Intentions from Pregnancy to 1 Year Postnatally: Impact of Choice of Measure, Timing of Assessment, Women’s Characteristics and Outcome of Pregnancy Abstract Objectives Retrospective, cross-sectional estimates of pregnancy intention, as used in the Demographic Health Survey (DHS), are the global norm. The London Measure of Unplanned Pregnancy (LMUP) is a newer, psychometrically validated measure which may be more reliable. This paper assesses the reliability of the LMUP and the DHS question over the first postnatal year and explores the effects of maternal characteristics or pregnancy outcome on reported pregnancy intention. Methods We compared the test–retest reliability of the LMUP (using the AC coefficient) and DHS question (using the weighted Kappa) over the first postnatal year using data from Malawian women. We investigated the effect of maternal characteristics and pregnancy outcome using t-tests, Chi squared or Fisher’s exact tests, and calculated odds ratios to estimate effect size. Results The DHS question was associated with a statistically significant decrease in the prevalence of unplanned pregnancies from 1-to-12 months postnatally; the LMUP was not. The LMUP had moderate to substantial reliability (0.51–0.66); the DHS had moderate reliability (0.56–0.58). The LMUP’s stability was not related to any of the factors examined; the stability of the DHS varied by marital status (p = 0.033), number of children (p = 0.048) and postnatal depression (p < 0.001). Both underestimated unintended pregnancy postnatally vis-à-vis the LMUP in pregnancy. Conclusions for Practice The LMUP is a more reliable measure of pregnancy intention than the DHS in the first postnatal year and does not vary by maternal characteristics or pregnancy outcome. The LMUP should become the gold-standard for measuring pregnancy intention and should be collected in pregnancy or at the first postnatal opportunity.

“The Closer, the Better:” The Role of Telehealth in Increasing Contraceptive Access Among Women in Rural South Carolina Abstract Background Rural populations face unique health disparities that prevent women from accessing reproductive health care services. Telehealth initiatives offer a health care delivery tool to increase access to contraception. Objective To understand women’s contraceptive needs and perceptions of accessing contraception through telehealth services. Methods Researchers conducted 52 in-depth interviews with women ages 18–44 years living in five rural counties in South Carolina from May to July 2015. Researchers employed constant comparative data analysis using HyperRESEARCH 3.7.2. Results Most participants identified as Black (62%) or White (28%). Findings suggest successful telehealth interventions should accommodate women’s complex and nuanced community views, including benefits and barriers of telehealth, to improve access to contraceptive methods in rural locations. In addition, telehealth initiatives should frame contraception as contributing to women’s overall health and well-being. Conclusions for Practice Telehealth initiatives may address barriers to contraceptive access in rural locations. Findings from this study offer theoretical and practical opportunities to guide telehealth interventions that support and empower women’s access to contraceptive methods in rural areas.

Change and Continuity in Low-Income Working Mothers’ Food Practices for Young Children in Response to Life Events Abstract Objective To understand how changes in low-income mothers’ work, home, and childcare environments impact their food practices for young children. Methods The grounded theory, theory-guided, design included two in-depth qualitative interviews (6 to 8 months apart) with each of 19 low income, working/student mothers of Head Start children, living in a rural county in Upstate New York. Interviews covered mothers’ experiences of employment, school, family, household, and childcare events over one school year and whether and how events changed child food practices. Emergent themes related to mothers’ experiences of life events, with attention to influences on child food practices, were open-coded using a constant comparative approach. A life course approach and a transactional model of the stress process informed interpretation. Results Within the study period, most mothers reported at least one life event, with many experiencing one or more changes in employers, job schedules, residence, household members, or childcare situation. Emergent patterns of adjustment in child food practices linked with life events were shaped by mothers’ appraisals of life events, the availability of coping resources, and their adaptations to events, based on temporal, financial, and social resources. The findings support a view of child feeding informed by the transactional model of stress. Conclusions Instability in work, family, household, and childcare highlight changing contexts for child food practices in daily life. Research and practice should acknowledge the changing nature of the child feeding context and the need for children’s caregivers to make adjustments in response to changing resources.

Associations Between Maternal Experiences of Discrimination and Biomarkers of Toxic Stress in School-Aged Children Abstract Objective To examine associations between maternal experiences of discrimination and child biomarkers of toxic stress in a multiethnic, urban sample of mothers and children (4–9 years). Methods Data were drawn from a cross-sectional study of maternal–child dyads (N = 54) living in low-income neighborhoods in New Haven, Connecticut, USA. Mothers reported experiences of discrimination. Noninvasive biomarkers of toxic stress were collected to assess neuroendocrine (hair cortisol), immune (salivary cytokines, c-reactive protein), and cardiovascular (blood pressure) functioning in children. Results Maternal experiences of discrimination were associated with increased log-transformed salivary interleukin-6 (IL-6) levels in children (β = 0.15, p = 0.02). Conclusions Vicarious racism, or indirect exposure to discrimination experienced by caregivers, is associated with poor health outcomes for children. Immune pathways may be a biological mechanism through which racial discrimination “gets under the skin,” but additional research is needed to fully understand these relationships. Uncovering the physiological mechanisms linking vicarious racism with child health is an important step towards understanding possible early roots of racial and ethnic health inequities.

Online Simulated Cases Assess Retention of Virtual Neighborhood Tour Curriculum Abstract Background Learning to identify and address social determinants of health (SDH) is a crucial component of pediatric residency training. A virtual tour of an impoverished neighborhood previously demonstrated efficacy in increasing residents’ self-assessed knowledge and competence, but its impact on performance has not yet been reported. Online simulated cases are emerging as feasible assessment tools to measure trainees’ skills across various healthcare settings. We developed online simulated cases to evaluate residents’ retention of the virtual tour’s key SDH-related learning objectives 1 month after completing this curriculum. Methods Three online simulated cases with interpolated open-ended questions were created to assess residents’ ability to identify SDH, recommend appropriate resources, and display empathy. Scoring rubrics to objectively evaluate responses were developed and borderline scores were decided by a team of educators. Results 19 residents participated. Mean scores for all cases exceeded pre-established borderline scores (statistically significant in two of the three cases). More than 90% of residents identified relevant SDH in the primary care and emergency department cases. Ninety-five percent of residents recommended appropriate resources in all cases, and 89% displayed empathy. Discussion Residents’ performance in online simulated cases demonstrated retention and application of the virtual tour’s learning objectives, including recognizing SDH, offering appropriate resources, and displaying empathy, which supports the long-term effectiveness of the virtual tour curriculum to train pediatricians about SDH. Online simulated cases provided a standardized and cost-effective way to measure residents’ skills related to curricular uptake, suggesting that this assessment approach may be adapted to evaluate other educational interventions.