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Vreeman R.C.,Indiana University | Vreeman R.C.,USAID Academic Model Providing Access to Healthcare AMPATH Partnership | Vreeman R.C.,Regenstrief Institute Inc. | Vreeman R.C.,Childrens Health Services Research | And 8 more authors.
International Journal of Behavioral Medicine | Year: 2014

Background: There are 2.3 million children living with HIV worldwide, almost 90 % of whom live in sub-Saharan Africa. Access to antiretroviral therapy (ART) for HIV treatment has dramatically increased in resource-limited settings in recent years and allows more HIV-infected children to survive into adolescence and adulthood. Purpose: Our objective was to improve the understandability of pediatric antiretroviral adherence measurement items for use in resource-limited settings through cognitive interviewingwith pediatric caregivers and HIV-infected adolescents in Kenya. Methods: We compiled adherence measurement items through a systematic literature review and qualitative work. We conducted cognitive interviews assessing the items with caregivers of HIV-infected children enrolled in HIV care in Kenya and conducted group cognitive assessments with HIV-infected adolescents. We used verbal probing and guided "thinking aloud" to evaluate relevance, comprehension, recall, and sensitivity/acceptability. Analysis followed a systematic sequence of review, compiling data by item, and coding responses. Results: We interviewed 21Kenyan parents and guardians and 10 adolescents (mean age 15 years, SD 1.8) on antiretroviral therapy for a mean of 3.6 years. Cognitive interviews optimized item-response options, wording, and content. Some participants demonstrated difficulty with "think aloud" processes, but verbal probes were easily answered. Comprehension problems were found for key language concepts such "missed doses" and "having side effects." Key findings for response options included differences among responses to various recall periods, with preferences for the shortest (one 24-hday) and longest recall periods (1 month); difficulty describing specific drug information; benefits for including normalizing statements before asking for sensitive information; and challenges processing categorical frequency scales. Important content areas for inclusion included dose timing, disclosure, stigma, and food insecurity. Conclusions: Cognitive interviewing is a productive strategy for increasing the face validity and understandability of adherencemeasurement items, particularly across cultures. Interviews in Kenya suggested adherence measurement modifications of relevance for other resource-limited settings. © International Society of Behavioral Medicine 2012.


Lindberg D.M.,Brigham and Women's Hospital | Lindberg D.M.,Childrens Hospital Boston | Harper N.S.,Driscoll Childrens Hospital | Laskey A.L.,Childrens Health Services Research | Berger R.P.,University of Pittsburgh
Pediatric Emergency Care | Year: 2013

OBJECTIVE: Recently, it has been suggested that views of the hands, feet, spine, and pelvis should be omitted from routine skeletal surveys (SSs) because these fractures are rarely identified by SS. Our objective was to describe the prevalence of fractures to the hands, feet, spine, or pelvis among SSs obtained for children in a large, multicenter population who underwent consultation for physical abuse. METHODS: This was a retrospective secondary analysis of data from the Examining Siblings To Recognize Abuse research network, a consortium of 20 US child abuse teams who collected data for all children younger than 10 years who underwent consultation for concerns of physical abuse. This secondary analysis included data only from index children and excluded data from siblings and contacts. Consulting child abuse physicians reported the number of fractures identified and those that were detected by SS. RESULTS: Among 2049 initial SSs, 471 (23.0%) showed at least 1 previously unknown fracture including 49 (10.4%) that showed a fracture to the hands, feet, spine, or pelvis. In 10 cases, the SS identified at least 1 fracture of the hands, feet, spine, or pelvis when no other fractures were identified. CONCLUSIONS: A significant number of occult, abusive fractures would have been missed if SSs had omitted or deferred views of the hands, feet, spine, and pelvis. Given the risks associated with missed abuse, these views should be routinely included in the radiographic SS. Copyright © 2013 by Lippincott Williams & Wilkins.


Lindberg D.M.,Brigham and Women's Hospital | Lindberg D.M.,Childrens Hospital Boston | Shapiro R.A.,Cincinnati Childrens Hospital Medical Center | Laskey A.L.,Childrens Health Services Research | And 4 more authors.
Pediatrics | Year: 2012

OBJECTIVE: Siblings and other children who share a home with a physically abused child are thought to be at high risk for abuse, but rates of injury in these contact children are unknown and screening of contacts is highly variable. Our objective was to determine the prevalence of abusive injuries identified by a common screening protocol among contacts of physically abused children. METHODS: This is an observational, multicenter cross-sectional study of children evaluated for physical abuse, and their contacts, by 20 US child abuse teams who used a common screening protocol for the contacts of physically abused children with serious injuries. Contacts underwent physical examination if they were <5 years old, physical examination and skeletal survey (SS) if they were <24 months old, and physical examination, SS, and neuroimaging if they were <6 months old. RESULTS: Protocol-indicated SS identified at least 1 abusive fracture in 16 of 134 contacts (11.9%, 95% confidence interval [CI] 7.5-18.5) <24 months of age. None of these fractures had associated findings on physical examination. No injuries were identified by neuroimaging in 19 of 25 eligible contacts (0.0%, 95% CI 0.0-13.7). Twins were at substantially increased risk of fracture relative to nontwin contacts (odds ratio 20.1, 95% CI 5.8-69.9). CONCLUSIONS: SS should be obtained in the contacts of injured, abused children for contacts who are <24 months old, regardless of physical examination findings. Twins are at higher risk of abusive fractures relative to nontwin contacts. Copyright © 2012 by the American Academy of Pediatrics.


Hendrix K.S.,Childrens Health Services Research | Hendrix K.S.,Regenstrief Institute Inc | Downs S.M.,Childrens Health Services Research | Downs S.M.,Regenstrief Institute Inc | And 2 more authors.
Academic Pediatrics | Year: 2015

Objective Physicians typically respond to roughly half of the clinical decision support prompts they receive. This study was designed to test the hypothesis that selectively highlighting prompts in yellow would improve physicians' responsiveness. Methods We conducted a randomized controlled trial using the Child Health Improvement Through Computer Automation clinical decision support system in 4 urban primary care pediatric clinics. Half of a set of electronic prompts of interest was highlighted in yellow when presented to physicians in 2 clinics. The other half of the prompts was highlighted when presented to physicians in the other 2 clinics. Analyses compared physician responsiveness to the 2 randomized sets of prompts: highlighted versus not highlighted. Additionally, several prompts deemed high priority were highlighted during the entire study period in all clinics. Physician response rates to the high-priority highlighted prompts were compared to response rates for those prompts from the year before the study period, when they were not highlighted. Results Physicians did not respond to prompts that were highlighted at higher rates than prompts that were not highlighted (62% and 61%, respectively; odds ratio 1.056, P =.259, NS). Similarly, physicians were no more likely to respond to high-priority prompts that were highlighted compared to the year before, when the prompts were not highlighted (59% and 59%, respectively, χ2 = 0.067, P =.796, NS). Conclusions Highlighting reminder prompts did not increase physicians' responsiveness. We provide possible explanations why highlighting did not improve responsiveness and offer alternative strategies to increasing physician responsiveness to prompts. © 2015 Academic Pediatric Association.


Vreeman R.,Indiana University | Vreeman R.,Academic Model Providing Access to Healthcare AMPATH Partnership | Vreeman R.,Regenstrief Institute Inc. | Vreeman R.,Childrens Health Services Research | And 15 more authors.
BMC Medical Ethics | Year: 2012

Background: International collaborators face challenges in the design and implementation of ethical biomedical research. Evaluating community understanding of research and processes like informed consent may enable researchers to better protect research participants in a particular setting; however, there exist few studies examining community perspectives in health research, particularly in resource-limited settings, or strategies for engaging the community in research processes. Our goal was to inform ethical research practice in a biomedical research setting in western Kenya and similar resource-limited settings. Methods. We sought to use mabaraza, traditional East African community assemblies, in a qualitative study to understand community perspectives on biomedical research and informed consent within a collaborative, multinational research network in western Kenya. Analyses included manual, progressive coding of transcripts from mabaraza to identify emerging central concepts. Results: Our findings from two mabaraza with 108 community members revealed that, while participants understood some principles of biomedical research, they emphasized perceived benefits from participation in research over potential risks. Many community members equated health research with HIV testing or care, which may be explained in part by the setting of this particular study. In addition to valuing informed consent as understanding and accepting a role in research activities, participants endorsed an increased role for the community in making decisions about research participation, especially in the case of children, through a process of community consent. Conclusions: Our study suggests that international biomedical research must account for community understanding of research and informed consent, particularly when involving children. Moreover, traditional community forums, such as mabaraza in East Africa, can be used effectively to gather these data and may serve as a forum to further engage communities in community consent and other aspects of research. © 2012 Vreeman et al.; licensee BioMed Central Ltd.


Laskey A.L.,Indiana University | Laskey A.L.,Riley Hospital for Children | Laskey A.L.,Childrens Health Services Research | Stump T.E.,Indiana University | And 3 more authors.
Journal of Pediatrics | Year: 2013

Objective: To measure the yield of a skeletal survey in children ≤18 months old presenting with isolated skull fractures without significant intracranial injury. Study design: A retrospective chart review was conducted on all children ≤18 months old presenting with an isolated skull fracture not associated with a motor vehicle crash or shopping cart fall between January 1, 2004 and December 31, 2010. An institutional protocol requires a skeletal survey and social work consult on all such children. We analyzed the association of mechanism of injury, type of skull fracture, and presence of "red flags" with a positive skeletal survey using χ2 and Fisher exact tests. Results: Of 175 eligible patients, 150 (86%) underwent a skeletal survey. Of the 9 patients (6%) who had another fracture in addition to the presenting one, only 1 child was older than 6 months. Eight patients with additional fractures had a simple skull fracture (not complex) and 7 patients with other fractures had at least 1 red flag. Regarding skull fractures, the majority of long falls (81%) resulted in a simple skull fracture. Conclusion: The skeletal survey in patients with isolated skull fractures revealed additional fractures in 6% of patients. Thus, a skeletal survey may yield clinically and forensically relevant data in such patients. However, it may be possible to restrict the window for obtaining a skeletal survey to younger infants, particularly those who are premobile. Copyright © 2013 Mosby Inc.


Hendrix K.S.,Childrens Health Services Research | Sturm L.A.,Childrens Health Services Research | Zimet G.D.,Childrens Health Services Research | Meslin E.M.,Indiana University
American Journal of Public Health | Year: 2016

Childhood immunization involves a balance between parents' autonomy in deciding whether to immunize their children and the benefits to public health frommandating vaccines. Ethical concerns about pediatric vaccination span several public health domains, including those of policymakers, clinicians, and other professionals. In light of ongoing developments and debates, we discuss several key ethical issues concerning childhood immunization in the United States and describe how they affect policy development and clinical practice. We focus on ethical considerations pertaining to herd immunity as a community good, vaccine communication, dismissal of vaccine-refusing families from practice, and vaccine mandates. Clinicians and policymakers need to consider the nature and timing of vaccine-related discussions and invoke deliberative approaches to policymaking.


Coffelt T.A.,Indiana University | Bauer B.D.,Indiana University | Carroll A.E.,Indiana University | Carroll A.E.,Childrens Health Services Research
Pediatrics | Year: 2013

OBJECTIVE: To define the demographic, diagnostic, procedural, and episode of care characteristics for children admitted with chronic pain. METHODS: We used the Pediatric Health Information System database to obtain data on demographic characteristics, length of stay, readmission rates, diagnoses, and procedures for children admitted with chronic pain. Patients with sickle cell disease, cancer, burns, cerebral palsy, transplants, and ventilator-dependent children were excluded. RESULTS: A total of 3752 patients with chronic pain were identified from 2004 through 2010. Admissions increased by 831% over this time period. The mean age of these patients was 13.5 years, the most common race was white (79%), and female subjects outnumbered male subjects by 2.41 to 1. The most common admission and principal discharge diagnosis was abdominal pain; comorbid diagnoses were common, with a mean of 10 diagnoses per patient. In total, 65% of patients had a comorbid gastrointestinal diagnosis and 44% had a psychiatric diagnosis. The mean length of stay was 7.32 days, with an expected length of stay of 4.24 days; 12.5% were readmitted at least once within 1 year. They underwent a mean of 3.18 procedures per patient. CONCLUSIONS: The average child admitted with chronic pain is a teenaged female with a wide variety of comorbid conditions, many of which are gastrointestinal and psychiatric in nature. Admissions for chronic pain are rising and account for substantial resource utilization. Future studies should further characterize this population, with the overall objective of improving outcomes and optimizing cost-effective care. Copyright © 2013 by the American Academy of Pediatrics. © 2013 by the American Academy of Pediatrics.


PubMed | Childrens Health Services Research
Type: Clinical Trial | Journal: Journal of developmental and behavioral pediatrics : JDBP | Year: 2012

To conduct a pilot study to test the feasibility and acceptability of using childrens books to understand caregiver perceptions of parenting practices around common behavior challenges.A prospective 1-month pilot study was conducted in 3 community-based pediatric clinics serving lower income families living in central Indianapolis. One hundred caregivers of 4- to 7-year-old children presenting for a well-child visit chose 1 of 3 available childrens books that dealt with a behavioral concern the caregiver reported having with the child. The book was read aloud to the child in the caregivers presence by a trained research assistant and given to the families to take home. Outcomes measured were caregiver intent to change their interaction with their child after the book reading, as well as caregiver reports of changes in caregiver-child interactions at 1 month.Reading the book took an average of 3 minutes. Most (71%) caregivers reported intent to change after the book reading; two-thirds (47/71) were able to identify a specific technique or example illustrated in the story. One month later, all caregivers remembered receiving the book, and 91% reported reading the book to their child and/or sharing it with someone else. Three-fourths of caregivers (60/80) reported a change in caregiver-child interactions.The distribution of childrens books with positive parenting content is a feasible and promising tool, and further study is warranted to see whether these books can serve as an effective brief intervention in pediatric primary care practice.

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