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1.  Low Parental Literacy Associated with Worse Asthma Care Measures in Children 
To determine if parental literacy is related to emergency department visits, hospitalizations, and days of school missed for children with asthma.
We performed a retrospective cohort study at a university pediatric clinic. We enrolled children between 3 and 12 years old with a diagnosis of asthma and a regular source of care at the site of the study and their parent or guardian. Primary asthma care measures included self-reported rates of emergency department visits, hospitalizations, and days of school missed. Secondary asthma care measures included rescue and controller medication use, classification of asthma severity and parental asthma-related knowledge.
We enrolled 150 children and their parents. Twenty-four percent of the parents had low literacy. Children of parents with low literacy had greater incidence of emergency department visits (adjusted incidence rate ratio [IRR] 1.5; 95% CI 1.1, 2.1), hospitalizations (IRR 3.2; 1.4, 7.3), and days missed from school (IRR 2.5; 2.1, 3.0) even after adjusting for asthma-related knowledge, disease severity, medication use and other socio-demographic factors. Parents with low literacy had less asthma-related knowledge, and their children were more likely to have moderate or severe persistent asthma and had greater use of rescue medications.
Low parental literacy is associated with worse care measures for children with asthma.
PMCID: PMC1797805  PMID: 17261479
asthma; literacy; children; parents; hospitalization
2.  Procedural sedation in paediatric minor procedures: a prospective audit on ketamine use in the emergency department 
Emergency Medicine Journal : EMJ  2004;21(3):286-289.
Objectives: To further evaluate the safety profile and efficacy of intramuscular ketamine for procedural sedation during paediatric minor procedures in the emergency department and to ascertain parental satisfaction with the treatment of their children.
Methods: A prospective audit of ketamine use in a UK district general hospital involving 89 children requiring minor procedures. Children received topical anaesthesia followed by an intramuscular injection of ketamine 4 mg/kg and intramuscular atropine 0.02 mg/kg. The procedure was assessed by way of a physician completed form and by evaluation of questionnaires given to parents to gauge levels of satisfaction.
Results: No child required admission to hospital and there were no serious complications. A high level of satisfaction was expressed by all the parents/guardians of the children treated.
Conclusions: High levels of satisfaction among parents and staff together with the avoidance of hospital admission and improved resource management should be a sufficient incentive for hospital trusts to consider the establishment of this type of service.
PMCID: PMC1726338  PMID: 15107364
3.  Immunization Status of Children Admitted to a Tertiary-care Hospital of North India: Reasons for Partial Immunization or Non-immunization 
Reasons for the low coverage of immunization vary from logistic ones to those dependent on human behaviour. The study was planned to find out: (a) the immunization status of children admitted to a paediatric ward of tertiary-care hospital in Delhi, India and (b) reasons for partial immunization and non-immunization. Parents of 325 consecutively-admitted children aged 12–60 months were interviewed using a semi-structured questionnaire. A child who had missed any of the vaccines given under the national immunization programme till one year of age was classified as partially-immunized while those who had not received any vaccine up to 12 months of age or received only pulse polio vaccine were classified as non-immunized. Reasons for partial/non-immunization were recorded using open-ended questions. Of the 325 children (148 males, 177 females), 58 (17.84%) were completely immunized, 156 (48%) were partially immunized, and 111 (34.15%) were non-immunized. Mothers were the primary respondents in 84% of the cases. The immunization card was available with 31.3% of the patients. All 214 partially- or completely-immunized children received BCG, 207 received OPV/DPT1, 182 received OPV/DPT2, 180 received OPV/DPT3, and 115 received measles vaccines. Most (96%) received pulse polio immunization, including 98 of the 111 non-immunized children. The immunization status varied significantly (p<0.05) with sex, education of parents, urban/rural background, route and place of delivery. On logistic regression, place of delivery [odds ratio (OR): 2.3, 95% confidence interval (CI) 1.3–4.1], maternal education (OR=6.94, 95% CI 3.1–15.1), and religion (OR=1.75, 95% CI 1.2–3.1) were significant (p<0.05). The most common reasons for partial or non-immunization were: inadequate knowledge about immunization or subsequent dose (n=140, 52.4%); belief that vaccine has side-effects (n=77, 28.8%); lack of faith in immunization (n=58, 21.7%); or oral polio vaccine is the only vaccine required (n=56, 20.9%. Most (82.5%) children admitted to a tertiary-care hospital were partially immunized or non-immunized. The immunization status needs to be improved by education, increasing awareness, and counselling of parents and caregivers regarding immunizations and associated misconceptions as observed in the study.
PMCID: PMC2980896  PMID: 20635642
Child; Immunization; Vaccination; India
4.  Patterns of susceptibility in an outbreak of Bordetella pertussis: Evidence from a community-based study 
To describe an outbreak of Bordetella pertussis and to assess which factors were associated with the development of clinical pertussis in children and adults during the outbreak.
A case series was described to define the epidemiology of the pertussis outbreak. A school-based survey of children was used to measure the incidence of clinical pertussis over the previous six months. Vaccination records from the local public health facility were used to look at the relationship between age and vaccination parameters, and susceptibility to clinically diagnosed pertussis. A cross-sectional survey of teachers, parents and some hospital workers was used to assess these associations in adults.
An outbreak of pertussis in an isolated northern community in British Columbia.
All children in the community who attend daycare, kindergarten or school, and their parents were surveyed. In addition, some health care workers and mothers of preschool children were surveyed.
A total of 31 suspected cases of pertussis were identified over a three-month period. Ninety per cent of the affected children who had available vaccination records had received four or five doses of pertussis vaccine. Sixty per cent of the town's 209 children returned completed surveys. Of these, 69% had available vaccination records. Thirty-six children (28%) reported symptoms that fit the case definition for pertussis over the previous three months. Attack rates were highest for the group of children aged 10 to 14 years. In a multivariate logistic regression analysis, receiving prophylactic medication and an increased number of years from the last vaccine dose were found to be significant predictors for developing pertussis. Thirty-four per cent of the estimated 291 adults in the community returned completed surveys. The attack rate of pertussis in the adults was only 9%. Being a member of the school staff and/or having a household contact with pertussis were significant predictors of developing pertussis.
Immunity to pertussis appears to wane during childhood. Peak susceptibility appears to be during early adolescence. Adults do not seem to be at greater risk than adolescents for developing the disease, but it seems unlikely that this is due to better immunity. Rather, it is probably related to a lower risk of exposure to pertussis and a lower rate of progression to symptomatic disease when adults are infected.
PMCID: PMC2094882  PMID: 18159406
Immunity; Pertussis; Vaccination
5.  Acute appendicitis in young children in the Belfast urban area: 1985-1992. 
The Ulster Medical Journal  1994;63(1):3-7.
Eighty-one cases of acute appendicitis in children aged less than six years were identified in the Belfast urban area between 1985 and 1992. Appendiceal perforation, found in 43%, was related to symptom duration but not to age at presentation. Prolongation of symptoms was related to parental delay in seeking medical advice (52% > 36 hours), delayed or inappropriate general practitioner referral to hospital (19%) and diagnostic delay following surgical consultation (12% > 12 hours). Diagnostic delay in hospital was usually the result of nonspecificity of symptoms and signs and was therefore largely unavoidable. Delayed referral from general practice did not contribute unnecessarily to appendiceal perforation, and given that an individual general practitioner will see a case of preschool appendicitis once in 30 years, diagnostic accuracy was remarkably high.
PMCID: PMC2449084  PMID: 8658993
6.  Developmental delays and dental caries in low-income preschoolers in the USA: a pilot cross-sectional study and preliminary explanatory model 
BMC Oral Health  2013;13:53.
Anecdotal evidence suggests that low-income preschoolers with developmental delays are at increased risk for dental caries and poor oral health, but there are no published studies based on empirical data. The purpose of this pilot study was two-fold: to examine the relationship between developmental delays and dental caries in low-income preschoolers and to present a preliminary explanatory model on the determinants of caries for enrollees in Head Start, a U.S. school readiness program for low-income preschool-aged children.
Data were collected on preschoolers ages 3–5 years at two Head Start centers in Washington, USA (N = 115). The predictor variable was developmental delay status (no/yes). The outcome variable was the prevalence of decayed, missing, and filled surfaces (dmfs) on primary teeth. We used multiple variable Poisson regression models to test the hypothesis that within a population of low-income preschoolers, those with developmental delays would have increased dmfs prevalence than those without developmental delays.
Seventeen percent of preschoolers had a developmental delay and 51.3% of preschoolers had ≥1 dmfs. Preschoolers with developmental delays had a dmfs prevalence ratio that was 1.26 times as high as preschoolers without developmental delays (95% CI: 1.01, 1.58; P < .04). Other factors associated with increased dmfs prevalence ratios included: not having a dental home (P = .01); low caregiver education (P < .001); and living in a non-fluoridated community (P < .001).
Our pilot data suggest that developmental delays among low-income preschoolers are associated with increased primary tooth dmfs. Additional research is needed to further examine this relationship. Future interventions and policies should focus on caries prevention strategies within settings like Head Start classrooms that serve low-income preschool-aged children with additional targeted home- and community-based interventions for those with developmental delays.
PMCID: PMC3906997  PMID: 24119240
7.  Parental Delay or Refusal of Vaccine Doses, Childhood Vaccination Coverage at 24 Months of Age, and the Health Belief Model 
Public Health Reports  2011;126(Suppl 2):135-146.
We evaluated the association between parents' beliefs about vaccines, their decision to delay or refuse vaccines for their children, and vaccination coverage of children at aged 24 months.
We used data from 11,206 parents of children aged 24–35 months at the time of the 2009 National Immunization Survey interview and determined their vaccination status at aged 24 months. Data included parents' reports of delay and/or refusal of vaccine doses, psychosocial factors suggested by the Health Belief Model, and provider-reported up-to-date vaccination status.
In 2009, approximately 60.2% of parents with children aged 24–35 months neither delayed nor refused vaccines, 25.8% only delayed, 8.2% only refused, and 5.8% both delayed and refused vaccines. Compared with parents who neither delayed nor refused vaccines, parents who delayed and refused vaccines were significantly less likely to believe that vaccines are necessary to protect the health of children (70.1% vs. 96.2%), that their child might get a disease if they aren't vaccinated (71.0% vs. 90.0%), and that vaccines are safe (50.4% vs. 84.9%). Children of parents who delayed and refused also had significantly lower vaccination coverage for nine of the 10 recommended childhood vaccines including diphtheria-tetanus-acellular pertussis (65.3% vs. 85.2%), polio (76.9% vs. 93.8%), and measles-mumps-rubella (68.4% vs. 92.5%). After adjusting for sociodemographic differences, we found that parents who were less likely to agree that vaccines are necessary to protect the health of children, to believe that their child might get a disease if they aren't vaccinated, or to believe that vaccines are safe had significantly lower coverage for all 10 childhood vaccines.
Parents who delayed and refused vaccine doses were more likely to have vaccine safety concerns and perceive fewer benefits associated with vaccines. Guidelines published by the American Academy of Pediatrics may assist providers in responding to parents who may delay or refuse vaccines.
PMCID: PMC3113438  PMID: 21812176
8.  Focusing on flu 
Human Vaccines & Immunotherapeutics  2012;8(10):1395-1400.
School-located immunization programs (SLIP) will only be successful if parents consent to their children's participation. It is critical to understand parent perspectives regarding the factors that make them more or less likely to provide that consent. Organizations creating SLIPs will be able to capitalize on the aspects of SLIPs that parents appreciate, and address and correct issues that may give rise to parent concerns. This study involved five focus groups among the parents of school students in a large, urban school district. Findings highlight the broad range of concepts important to parents when considering participation in a SLIP. The safety and trust issues regarding vaccines in general that are so important to parents are also important to parents when considering participation in a SLIP. Effective communication strategies that include assurances regarding tracking of information and the competence and experience of immunizers will be helpful when addressing parents regarding SLIPs. In addition, parents were very cognizant of and positive regarding the public health benefits associated with SLIPs. Further study among larger populations of parents will further refine these ideas and aid in the development of successful influenza vaccine SLIPs that directly address and communicate with parents about the issues most important to them.
PMCID: PMC3660758  PMID: 23095868
adolescent immunization; school-located immunization; influenza vaccine; parents; focus groups
9.  "Immunization mobile" brings protection to children in southeastern Idaho. 
Public Health Reports  1987;102(5):543-545.
The problem that needs to be addressed is the 58 percent immunity level among 2-year-olds in southeastern Idaho, a level created by the indifference or fear of parents. Southeastern Idaho has the highest birth rate of any region in the State, and this situation has created a large group of children susceptible to vaccine-preventable diseases. The mobile unit, which consists of a specially equipped motor home, allows easy access to immunizations for groups of children and their parents. A search of the computerized record system installed in the mobile unit can provide data on past immunizations for each registered child. The target audience for the mobile unit's visits is church groups because of the particular cultural demographics of this region. In 1987, the District Seven Health Department, a State- and county-funded agency, expects to increase the number of doses of vaccine given by 3,000 over the 19,953 given in 1986. The "Shots for Tots" program is unique in the State of Idaho. Its expansion may be anticipated as the unit becomes better known in the region. The alternative to using aggressive, innovative techniques to motivate people to become immunized is disease.
PMCID: PMC1477901  PMID: 3116586
10.  Don’t Ask, Don’t Tell: Parental Nondisclosure of Complementary and Alternative Medicine and Over-the-Counter Medication Use in Children’s Asthma Management 
Parent-healthcare provider (HCP) communication is an important component of pediatric asthma management. Given the high prevalence of complementary and alternative medicine (CAM) and over-the-counter (OTC) medication use among this population, it is important to examine parental nondisclosure of these asthma management strategies.
One-time interview and one-year retrospective medical record review with 228 parents of 5–12 year old children with asthma enrolled from 6 pediatric primary care practices examining parental nondisclosure of CAM and OTC medication use, reasons for nondisclosure, medical record documentation of CAM usage, and association between parent-HCP relationship and nondisclosure.
Seventy-one percent of parents reported using CAM and/or OTC medication for children’s asthma management and 54% of those parents did not disclose usage. Seventy-five percent “did not think” to discuss it. Better parent-HCP relationship led to decreased nondisclosure.
HCPs can play an important role in creating an environment where parents feel comfortable sharing information about their children’s asthma management strategies in order to arrive at a shared asthma management plan for the child leading to improved asthma health outcomes.
PMCID: PMC2517627  PMID: 18590866
11.  Parents' attitudes to measles immunization 
A study of a cohort of children in Maidstone Health Authority examined the reasons for the failure to achieve targets for the uptake of measles immunization. Parents were interviewed before they were notified about measles immunization to determine their attitudes, beliefs and intentions regarding measles immunization and a further review was held with those whose child had no record of the immunization by the age of 20 months. The initial interview showed that most parents have a favourable attitude to measles immunization. However, many lacked knowledge, especially about valid contraindications, and claimed not to have received advice from a doctor or health visitor. The most common reasons for non-uptake of measles immunization were: the child had already had measles, concern about contraindications and delay owing to illness. This points to the importance of increasing doctors' and health visitors' knowledge of Department of Health and Social Security guidelines regarding valid contraindications and to the role of health visitors in promoting uptake. However there is also evidence that the gap between actual and target levels of uptake may be less than official figures suggest.
PMCID: PMC1710608  PMID: 3668921
12.  Public Health Insurance in Oregon: Underenrollment of Eligible Children 
American Journal of Public Health  2011;101(5):891-898.
We identified characteristics of Oregon children who were eligible for Medicaid or the Children's Health Insurance Program (CHIP) but were not enrolled in January 2005. We also assessed whether parents' confusion regarding their children's status affected nonenrollment.
We conducted cross-sectional analyses of linked statewide food stamps and Medicaid and CHIP administrative databases (n|=|10|175) and primary data from a statewide survey (n|=|2681).
More than 20% of parents with children not administratively enrolled in Medicaid or CHIP reported that their children were enrolled. Parents of 11.3% of children who were administratively enrolled reported that they were not. Eligible but unenrolled children had higher odds of being older, having higher family incomes, and having employed parents and uninsured parents.
These findings reveal an important discrepancy between administrative data and parent-reported access to public health insurance. This may stem from transient coverage or confusion among parents and may result in underutilization of health insurance for eligible children.
PMCID: PMC3076391  PMID: 21421944
13.  Barriers to medical care for white, black, and Hispanic American children. 
As demonstrated by efforts to expand Medicaid coverage for poor and needy children, removing barriers to medical care continues to be an important social policy goal. Data from the 1987 National Medical Expenditure Survey, a multistage probability sample of 15,000 US households, was used to examine some of the barriers that black and Hispanic children encounter in obtaining access to medical care. Results from the 1987 study indicate that black and Hispanic children were more likely than white children to be poor, uninsured members of single-parent households, and to have to wait longer to see a medical provider. Yet differences in waiting time at the usual source of care remained after controlling for insurance. In 1987, 18.6% of uninsured white children were without a usual source of care compared with 28.4% and 25.2% of uninsured black and Hispanic children, respectively. Furthermore, 17.6% of uninsured white children made at least one routine visit to a physician during 1987, while only 11.4% and 10.6% of the uninsured black and Hispanic children, respectively, saw a physician for a regular checkup.
PMCID: PMC2571899  PMID: 8478969
14.  Pediatric hospital admissions for measles. Lessons from the 1990 epidemic. 
Western Journal of Medicine  1996;165(1-2):20-25.
To examine the descriptive epidemiology of serious measles complications and associated hospital costs during a major epidemic, we used California population-based hospital discharge data to identify hospital admissions for measles during 1986 through 1990 (ICD-9 code 055, n = 4,201). We examined 5-year trends and, for 1990 pediatric epidemic cases (n = 2,234), sociodemographic and hospital admission financial data. Hospital admission rates for measles rose significantly between 1986 and 1990. During the 1990 epidemic, preschool children aged 1 to 5 years, Medi-Cal (California's Medicaid) beneficiaries, Hispanics, and those living in urban counties accounted for most hospital admissions. Young infants and residents of southern California and the San Joaquin Valley had the highest risks. Medi-Cal beneficiaries and Asian children were at an increased risk for death during the hospital stay. The average hospital admission cost was $8,201, and the average length of hospital stay was 4.6 days. Hospital costs amounted to $18 million, two thirds of which was paid for by Medi-Cal. Measles is a serious disease that can result in severe complications requiring lengthy and costly hospital stays. We must remain alert to its continuing threat, complications, and resulting financial burdens.
PMCID: PMC1307536  PMID: 8855680
15.  Occurrence and repetition of hospital admissions for accidents in preschool children. 
BMJ : British Medical Journal  1991;302(6767):16-19.
OBJECTIVES--To examine trends over time in the rates of admission to hospital for accidents of preschool children and to study patterns of repeated admissions for accidents in these children. DESIGN--Analysis of linked, routine abstracts of hospital inpatient records for accidents. SETTING--Six districts in the Oxford Regional Health Authority covered by the Oxford record linkage study. SUBJECTS--Records for 19,427 children aged 5 years and under at the time of first recorded admission to hospital. MAIN OUTCOME MEASURE--Number of admissions to hospital. RESULTS--Records were analysed in three groups: person based annual admission rates were calculated for each calendar year; each child's first recorded admission in 1976-85 was identified, and the child's record was followed up by linkage for one year from that admission; each child's first recorded admission in 1976-81 was identified and followed up for five years. Overall, 19,427 children from an average annual resident population of 163,000 children in 1976-86 had 20,657 admissions for accidents before they were 6 years of age. Of these admissions 13,983 were for injuries, 5717 for poisonings, and 957 for burns. Admission rates declined after 1976 for poisoning, but no substantial changes over time were found in admission rates for injuries or burns. A total of 17,724 children were followed up for one year and 10,889 for five years; 470 (2.6%) of the children who were followed up for one year and 926 (8.5%) of those followed up for five years had at least one further admission for an accident. Of those followed up for one year the 4 and 5 year old children were least likely and those under 1 and 1 year old were most likely to have a further admission for an accident. The number of children who had more than one accident was greater than would be expected if accidents were random occurrences. Those who had a poisoning at first admission were more likely to have another poisoning than an injury or burn; and those who had a burn at first admission were more likely to have another burn. CONCLUSIONS--Hospital admissions for accidents in children are common: on average 1 child in 88 in this population was admitted each year. Multiple admissions are uncommon but none the less occur more often than would be expected by chance.
PMCID: PMC1668767  PMID: 1991180
16.  Opportunistic immunisation in hospital 
Archives of Disease in Childhood  1999;81(5):422-425.
AIM—To assess the potential for administering catch up and scheduled immunisations during hospital admission.
METHODS—Immunisation status according to the child's principal carer was checked against official records for 1000 consecutively admitted preschool age children. Junior doctors were instructed to offer appropriate vaccination before discharge, and consultants were asked to reinforce this proactive policy on ward rounds.
RESULTS—Excluding those children who were not fully immunised against pertussis through parental choice, 142 children (14.2%) had missed an age appropriate immunisation and 41 were due a scheduled immunisation. None had a valid contraindication. Only 43 children were offered vaccination on the ward but uptake was 65% in this group.
CONCLUSIONS—Admission to hospital provides opportunities for catch up and routine immunisations and can contribute to the health care of an often disadvantaged group of children. These opportunities are frequently missed. Junior doctors must be encouraged to see opportunistic immunisation as an important part of their routine work.

PMCID: PMC1718117  PMID: 10519717
17.  Increasing access to dental care for medicaid preschool children: the Access to Baby and Child Dentistry (ABCD) program. 
Public Health Reports  2000;115(5):448-459.
OBJECTIVE: Washington State's Access to Baby and Child Dent stry (ABCD) Program, first implemented in Spokane County in 1995, offers extended dental benefits to participating Medicaid-enrolled children and higher fees for certified providers. This study aimed to determine the program's effect on children's dental utilization and dental fear, and on parent satisfaction and knowledge. METHODS: The study used a posttest-only comparison group design. Trained interviewers conducted telephone interviews with 465 parents of chi dren ages 13 to 36 months (49% ABCD, 51% Medicaid-enrolled children not in ABCD). One year later, 282 of 465 parents completed a follow-up survey. Utilization and expenditures were calculated from Medicaid claims. RESULTS: Forty-three percent of children in the ABCD Program visited a dentist in the follow-up year, compared with 12% of Medicaid-enrolled children not in the ABCD Program. An ABCD child was 5.3 times as likely to have had at least one dental visit as a child not in the program. ABCD children were 4 to 13 times as likely to have used specific dental services. Parents of ABCD children were more likely to report having ever tried to make a dental appointment, less likely to report that their children were fearful of the dentist, and were more satisfied, compared to parents of non-ABCD children. CONCLUSION: The authors conclude that the ABCD Program was effective in increasing access for preschool children enrolled in Medicaid, reducing dental fear, and increasing parent satisfaction.
PMCID: PMC1308601  PMID: 11236017
18.  School-Based Influenza Vaccination: Parents’ Perspectives 
PLoS ONE  2014;9(3):e93490.
School-age children are important drivers of annual influenza epidemics yet influenza vaccination coverage of this population is low despite universal publicly funded influenza vaccination in Alberta, Canada. Immunizing children at school may potentially increase vaccine uptake. As parents are a key stakeholder group for such a program, it is important to consider their concerns.
We explored parents’ perspectives on the acceptability of adding an annual influenza immunization to the immunization program that is currently delivered in Alberta schools, and obtained suggestions for structuring such a program.
Forty-eight parents of children aged 5-18 years participated in 9 focus groups. Participants lived in urban areas of the Alberta Health Services Calgary Zone.
Three major themes emerged: Advantages of school-based influenza vaccination (SBIV), Disadvantages of SBIV, and Implications for program design & delivery. Advantages were perceived to occur for different populations: children (e.g. emotional support), families (e.g. convenience), the community (e.g. benefits for school and multicultural communities), the health sector (e.g. reductions in costs due to burden of illness) and to society at large (e.g. indirect conduit of information about health services, building structure for pandemic preparedness, building healthy lifestyles). Disadvantages, however, might also occur for children (e.g. older children less likely to be immunized), families (e.g. communication challenges, perceived loss of parental control over information, choices and decisions) and the education sector (loss of instructional time). Nine second-level themes emerged within the major theme of Implications for program design & delivery: program goals/objectives, consent process, stakeholder consultation, age-appropriate program, education, communication, logistics, immunizing agent, and clinic process.
Parents perceived advantages and disadvantages to delivering annual seasonal influenza immunizations to children at school. Their input gives a framework of issues to address in order to construct robust, acceptable programs for delivering influenza or other vaccines in schools.
PMCID: PMC3970961  PMID: 24686406
19.  A controlled trial of parent initiated and conventional preschool health surveillance using personal child health records 
Archives of Disease in Childhood  1999;80(6):507-510.
OBJECTIVES—A comparison of parent initiated preschool surveillance, using personal child health records, with the then current system of child health surveillance using child health records.
DESIGN—Prospective, controlled trial with randomisation of five general practices into two groups.
SETTING—Five general practices, a well baby clinic, and an orthoptic clinic at Yeovil District Hospital.
SUBJECTS—538 babies born between 1 April 1992 and 1 November 1994, from within the five general practices.
MAIN OUTCOME MEASURES—The number of screenable abnormalities in the two groups that were missed in the first 3 years of a baby's life.
RESULTS—163 babies from the parent initiated preschool surveillance group and 107 from the conventional group completed the study. Although all the mothers from the parent initiated preschool surveillance group understood the concept of parent initiated surveillance, 117 stated their health visitor had made their appointments. Only 45 mothers made their own appointments. The abnormality rates were: 12 of 163 and eight of 107 at 1 year and nine of 163 and six of 107 at 3 years. No medically important conditions were missed. Most mothers did not want to make their own appointments because it was inconvenient. The system was unpopular with health visitors.
CONCLUSION—Parent initiated preschool surveillance is as safe as the current system. Implementing the idea involved a small change in work practice and a large change conceptually for some of the primary health care team. It was not adopted in east Somerset.

PMCID: PMC1717953  PMID: 10331997
20.  Toward estimating the impact of changes in immigrants' insurance eligibility on hospital expenditures for uncompensated care 
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 gave states the option to withdraw Medicaid coverage of nonemergency care from most legal immigrants. Our goal was to assess the effect of PRWORA on hospital uncompensated care in the United States.
We collected the following state-level data for the period from 1994 through 1999: foreign-born, noncitizen population and health uninsurance rates (US Census Current Population Survey); percentage of teaching hospitals (American Hospital Association Annual Survey of Hospitals); and each state's decision whether to implement the PRWORA Medicaid bar for legal permanent residents or to continue offering nonemergency Medicaid coverage using state-only funds (Urban Institute). We modeled uncompensated care expenditures by state (also from the Annual Survey of Hospitals) in both univariate and multivariable regression analyses.
When measured at the state level, there was no significant relationship between uncompensated care expenditures and states' percentage of noncitizen immigrants. Uninsurance rates were the only significant factor in predicting uncompensated hospital care expenditures by state.
Reducing the number of uninsured patients would most surely reduce hospital expenditures for uncompensated care. However, data limitations hampered our efforts to obtain a monetary estimate of hospitals' financial losses due specifically to the immigrant eligibility changes in PRWORA. Quantifying the impact of these provisions on hospitals will require better data sources.
PMCID: PMC140321  PMID: 12523939
21.  Who gives pain relief to children? 
OBJECTIVE: To compare pre-hospital parental administration of pain relief for children with that of the accident and emergency (A&E) department staff and to ascertain the reason why pre-hospital analgesia is not being given. DESIGN/METHODS: An anonymous prospective questionnaire was given to parents/guardians of children < 17 years. The children were all self referred with head injuries or limb problems including burns. The first part asked for details of pain relief before attendance in the A&E department. The second part of the questionnaire contained a section for the examining doctor and triage nurse to fill in. The duration of the survey was 28 days. RESULTS: Altogether 203 of 276 (74%) of children did not receive pain relief before attendance at the A&E department. Reasons for parents not giving pain relief included 57/203 (28%) who thought that giving painkillers would be harmful; 43/203 (21%) who did not give painkillers because the accident did not happen at home; and 15/203 (7%) who thought analgesia was the responsibility of the hospital. Eighty eight of the 276 (32%) did not have any painkillers, suitable for children, at home. A&E staff administered pain relief in 189/276 (68%). CONCLUSIONS: Parents often do not give their children pain relief before attending the A&E department. Parents think that giving painkillers may be harmful and often do not have simple analgesics at home. Some parents do not perceive that their child is in pain. Parents require education about appropriate pre-hospital pain relief for their children.
PMCID: PMC1343365  PMID: 10417932
22.  Impacts of Medicaid managed care on children. 
Health Services Research  2001;36(1 Pt 1):7-23.
OBJECTIVE: To assess the impact of switching from a fee-for-service (FFS) delivery system to managed care on access to, use of, and satisfaction with health care for children. DATA SOURCES/STUDY SETTING: A 1998 survey of Medicaid recipients in rural Minnesota. STUDY DESIGN: Using a quasi-experimental framework, we compare the experiences of children on Medicaid living in counties that had switched to managed care with those of children living in counties operating under FFS Medicaid. We address the impact of Medicaid managed care (MMC) on access to, use of, and satisfaction with care. DATA COLLECTION METHODS: A stratified random sample of children on Medicaid was drawn based on Medicaid enrollment files. Telephone interviews were conducted with the child's parent or guardian between March and June 1998. An overall response rate of 70 percent was achieved, yielding a sample of 1,106 children (814 in MMC and 792 in Medicaid FFS). PRINCIPAL FINDINGS: We find very few significant differences in access to, use of, or satisfaction with health care services for children under MMC relative to FFS. MMC did not change the patterns of health care service use or the location at which care is delivered, two major goals of MMC initiatives. CONCLUSIONS: Our results suggest that the Medicaid program's shift from FFS to managed care had little impact on the pattern of children's health care use, the location at which they obtained care, or the satisfaction with the care they received.
PMCID: PMC1089213  PMID: 11324745
23.  Can type of school be used as an alternative indicator of socioeconomic status in dental caries studies? A cross-sectional study 
Despite the importance of collecting individual data of socioeconomic status (SES) in epidemiological oral health surveys with children, this procedure relies on the parents as respondents. Therefore, type of school (public or private schools) could be used as an alternative indicator of SES, instead of collecting data individually. The aim of this study was to evaluate the use of the variable type of school as an indicator of socioeconomic status as a substitute of individual data in an epidemiological survey about dental caries in Brazilian preschool children.
This study followed a cross-sectional design, with a random sample of 411 preschool children aged 1 to 5 years, representative of Catalão, Brazil. A calibrated examiner evaluated the prevalence of dental caries and parents or guardians provided information about several individual socioeconomic indicators by means of a semi-structured questionnaire. A multilevel approach was used to investigate the association among individual socioeconomic variables, as well as the type of school, and the outcome.
When all significant variables in the univariate analysis were used in the multiple model, only mother's schooling and household income (individual socioeconomic variables) presented significant associations with presence of dental caries, and the type of school was not significantly associated. However, when the type of school was used alone, children of public school presented significantly higher prevalence of dental caries than those enrolled in private schools.
The type of school used as an alternative indicator for socioeconomic status is a feasible predictor for caries experience in epidemiological dental caries studies involving preschool children in Brazilian context.
PMCID: PMC3080355  PMID: 21457574
24.  Pediatric Head Trauma: Parent, Parent-Child and Family Functioning 2 Weeks after Hospital Discharge 
Journal of pediatric psychology  2005;31(6):608-618.
Investigate effects of pediatric head trauma on parent mental health, parent-child relationship and family functioning 2 weeks post-discharge.
97 mothers and 37 fathers of 106 preschool children hospitalized with head injury completed Mental Health Inventory (MHI), Parenting Stress Index, FACES II, and Multidimensional Scale of Perceived Social Support 2 weeks post-discharge and perceived injury severity, Parental Concerns Scale, Parental Stressor Scale: PICU, and MHI 24–48 hours after hospital admission.
Mental health post-discharge was related to social support and baseline mental health. Mothers’ parental distress was related to perceived injury severity and social support. Greater family cohesion was related to baseline mental health, social support, and being in a 2-parent family for mothers, and to social support for fathers.
Parents’ mental health and social support were important for parent mental health and family cohesion post-discharge. Perceived injury severity and parent reactions to hospitalization also played a role.
PMCID: PMC2424404  PMID: 16120765
head injury; family functioning; parent mental health; preschool children
25.  Clustering of developmental delays in Bavarian preschool children – a repeated cross-sectional survey over a period of 12 years 
BMC Pediatrics  2014;14:18.
While most children display a normal development, some children experience developmental delays compared to age specific development milestones assessed during school entry examination. Data exist on prevalence of delays in single areas, but there is lack of knowledge regarding the clustering patterns of developmental delays and their determinants.
During the observation period 1997-2008, 12 399 preschool children (5-7 years of age) in one district of Bavaria, Germany, were assessed in twelve schooling-relevant development areas. The co-occurrence of developmental delays was studied by means of Pearson’s correlation. Subsequently, a two-step cluster algorithm was applied to identify patterns of developmental delays, and multinomial logistic regression was conducted to identify variables associated with the specific patterns.
Fourteen percent of preschool children displayed developmental delays in one and 19% in two or more of the studied areas. Among those with at least two developmental delays, most common was the combination of delays in "fine motor skills" + "grapho-motor coordination" (in 9.1% of all children), followed by "memory/concentration" + "endurance" (5.8%) and "abstraction" + "visual perception" (2.1%). In the cluster analysis, five distinct patterns of delays were identified, which displayed different associations with male gender and younger age.
While developmental delays can affect single areas, clustering of multiple developmental delays is common. Such clustering should be taken into account when developing diagnostic tests, in pediatric practice and considering interventions to reduce delays.
PMCID: PMC3936812  PMID: 24450504
Developmental delays; Distribution pattern; Preschool children; Preventive medicine

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