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1.  Clinical significance of cough and wheeze in the diagnosis of asthma. 
Archives of Disease in Childhood  1996;75(6):489-493.
OBJECTIVES: (1) To determine the prevalence of cough, wheeze, and breathlessness, both as single symptoms and in combination, in primary schoolchildren and their relation to doctor diagnosed asthma. (2) To identify in areas with different levels of dust pollution whether questionnaire reported 'cough alone' (without wheeze or breathlessness) had similar risk factors to the questionnaire reported triad of 'cough, wheeze, and breathlessness'. SUBJECTS AND METHODS: Two cross sectional community surveys of primary schoolchildren (5-11 years) were performed in 1991 and 1993. Parent completed questionnaires related to socioeconomic and respiratory factors were distributed through 15 schools in three areas of Merseyside, one of which had a relatively high level of dust pollution. Data were analysed to determine the prevalence of different respiratory symptom patterns. Univariate and multiple logistic regressions were used to investigate the associations between respiratory symptom profiles and potential risk factors. RESULTS: The proportions of completed questionnaires that were returned were similarly high in both surveys, 92% in 1991 (1872 of 2035) and 87% in 1993 (3746 of 4288). The proportions of children with different respiratory symptom patterns were similar in the two surveys: in 1991, asymptomatic children 70.1% (1109 of 1583), those with cough alone 8.9% (141 of 1583), and children with the symptom triad of cough, wheeze, and breathlessness 8.3% (132 of 1583); the figures for 1993 were 69.5% (2144 of 3083), 9.2% (284 of 3083), and 7.3% (224 of 3083) respectively. The prevalence of doctor diagnosed asthma increased from 17.4% in 1991 to 22.1% in 1993. The symptom of cough alone was associated with going to school in an area of increased air pollution. The symptom triad of cough, wheeze, and breathlessness was associated with reported allergies, familial history of atopy and preterm birth. In 1991, of children with the symptom of cough alone one in eight were diagnosed asthmatic; twice as many doctors made the diagnosis on this basis in 1993. CONCLUSION: The respiratory symptom of cough alone and cough, wheeze, and breathlessness represent clinical responses to different specific risk factors. Cough alone was associated with the environmental factors of school in the dust exposed zone and dampness in the home, whereas cough, wheeze, and breathlessness related to allergic history and preterm birth, and may be the best surrogate of asthma. Diagnosis of asthma on the basis of cough alone partly explains the increased prevalence of doctor diagnosed asthma, especially in dust polluted areas.
PMCID: PMC1511809  PMID: 9014600
2.  Respiratory morbidity in Merseyside schoolchildren exposed to coal dust and air pollution. 
Archives of Disease in Childhood  1994;70(4):305-312.
A cross sectional study was carried out to determine whether schoolchildren in a specific locality exposed to pollution from steam coal dust have an excess of respiratory symptoms compared with children in control areas. A total of 1872 primary schoolchildren (aged 5-11 years) from five primary schools in the Bootle dock area of Liverpool (exposed area), five primary schools in South Sefton (control area), and five primary schools in Wallasey (control area) were studied. A questionnaire was distributed through the schools and was completed by the parents of the children. The questionnaire inquired about respiratory symptoms (cough, wheezing, and shortness of breath), allergy, atopy, smoking, and socioeconomic factors. Height, weight, and peak expiratory flow were measured. Compliance was good (92%) and similar in the three study areas. The children in the three areas were of similar mean age (7.5 years), height (1.24 m), sex ratio, and had a similar prevalence of paternal (6.2%) and maternal (7%) asthma. The exposed zone contained more unemployed parents (41, 29, and 29% respectively), more rented housing (64, 45, 34%), and more smoking parents (71, 60, 59%) than the control areas. Respiratory symptoms were significantly more common in the exposed area, including wheeze (25.0, 20.6, and 17.5%), excess cough (40.0, 23.4, and 25.1%), and school absences for respiratory symptoms (47.5, 35.9, and 34.9%). These differences remained significant even if the groups were subdivided according to whether or not parents smoked or were employed. Multiple logistic regression analysis confirmed the exposed zone as a significant risk factor for absenteeism from school due to respiratory symptoms (odds ratio 1.55, 95% confidence interval 1.17 to 2.06) after adjusting for confounding factors. Standard dust deposit gauges on three schools confirmed a significantly higher dust burden in the exposed zone. An increased prevalence of respiratory symptoms in primary schoolchildren exposed to coal dust is confirmed. Although the association with known coal dust pollution is suggestive a cross sectional study cannot confirm a casual relation and further studies are needed.
PMCID: PMC1029784  PMID: 8185364
3.  Sociocultural and psychological determinants in migrants for noncompliance with occlusion therapy for amblyopia 
Background
Compliance with occlusion therapy for amblyopia in children is low when their parents have a low level of education, speak Dutch poorly, or originate from another country. We determined how sociocultural and psychological determinants affect compliance.
Methods
Included were amblyopic children between the ages of 3 and 6, living in low socio-economic status (SES) areas. Compliance with occlusion therapy was measured electronically. Their parents completed an oral questionnaire, based on the “Social Position & Use of Social Services by Migrants and Natives” questionnaire that included demographics and questions on issues like education, employment, religion and social contacts. Parental fluency in Dutch was rated on a five-point scale. Regression analysis was used to describe the relationship between the level of compliance and sociocultural and psychological determinants.
Results
Data from 45 children and their parents were analyzed. Mean electronically measured compliance was 56 ± 44 percent. Children whose parents had close contact with their neighbors or who were highly dependent on their family demonstrated low levels of compliance. Children of parents who were members of a club and who had positive conceptualizations of Dutch society showed high levels of compliance. Poor compliance was also associated with low income, depression, and when patching interfered with the child’s outdoor activity. Religion was not associated with compliance.
Conclusions
Poor compliance with occlusion therapy seems correlated with indicators of social cohesion. High social cohesion at micro level, i.e., family, neighbors and friends, and low social cohesion on macro level, i.e., Dutch society, are associated with noncompliance. However, such parents tend to speak Dutch poorly, so it is difficult to determine its actual cause.
Electronic supplementary material
The online version of this article (doi:10.1007/s00417-011-1637-5) contains supplementary material, which is available to authorized users.
doi:10.1007/s00417-011-1637-5
PMCID: PMC3229699  PMID: 21399941
Amblyopia; Ethnic groups; Patient compliance; Social cohesion; Social class
4.  Frequency of Substance Abuse Among Adolescents 
Materia Socio-Medica  2013;25(4):265-269.
Introduction:
Drug addiction is one of the most prominent problems in many countries in transition, including Bosnia and Herzegovina. Age limit of drug addiction is shifted to the younger age groups, especially is troubling the increase in number of injection drug users. Our study was aimed to investigate the habits, attitudes and practices related to drug use among young people from the area of Sarajevo city. We can still feel the effects of the war, among which are the most important life without closest relatives, banishment and various types of war and post-war trauma.
Goals:
To determine the frequency of substance abuse among adolescents; Identify potentially relevant biological, psychological and socio economic characteristics of the adolescents; To explore adolescents attitudes towards drug use; Examine the general level of knowledge of adolescents about drugs and their effects.
Material and Methods:
The study was conducted on randomized sample of 502 students in two primary and three secondary schools in Sarajevo and Gracanica. To study used survey method. Survey instrument was a self-made questionnaire with the research variables. The obtained data were processed by a computer and statistically correlated. The study is of combined, retrospective, prospective and transversal type.
Results:
To the question “How many times have you consumed cannabis in the last 30 days” about 6% of the respondents have tried once or twice, while 1.5% use it daily, ecstasy have tried one or two times 2.25%, while 0.5% have daily use. Based on the obtained results it can be concluded that students at schools in Sarajevo consumed drugs 50% more than the children in Gracanica. Analyzing the age at which the subjects consumed the drug for the first time, we came to the conclusion that in the third year of high school only 8% of adolescents have tried any drugs before they turned 15 years. This percentage among eighth graders is about three times higher.
Conclusion:
Presented research results clearly suggest a strong contamination of the living environment of young people with different types of psychoactive substances. Offer of drugs is extensive and distribution network covers all the places where young people visits, including schools. It is clear that today’s teenagers sooner or later hear about drugs, see, get in touch with a “junkie” and have a chance to take the drugs if they want to. From our research, we found that the following factors: Marital status of parents, employment of parents, the number of family members, type of school and satisfaction with oneself are not crucial for the eventual drug use among young people. While, the biological status of the parents, educational status of parents, financial status of parents, the tendency of parents tobacco and alcohol use, adolescents’ attitude to parents, the harmony of relationships between parents, school performance, positive attitude toward the so-called light drugs, represent significant risk factors for adolescent populations.
doi:10.5455/msm.2013.25.265-269
PMCID: PMC3914750  PMID: 24511272
Drug use; adolescence; risk and protective factors; Bosnia and Herzegovina.
5.  Prevalence and socio-demographic correlates of the compliance with the physical activity guidelines in children and adolescents in Germany 
BMC Public Health  2012;12:714.
Background
Regular physical activity (PA) is a prerequisite for normal growth and maturation, health, and fitness of children and adolescents. Because of the growing evidence of the health benefits of regular PA, several national and international public health organisations have established PA guidelines. The purpose of this study was to assess the percentage of children and adolescents in Germany who meet the PA guideline of 60 minutes of moderate-to-vigorous PA each day and to evaluate socio-demographic correlates of compliance with the PA guideline.
Methods
The sample consists of 4,529 children and adolescents aged between 4 and 17 years who lived and were registered in the Federal Republic of Germany between 2003 and 2006. The compliance with the PA guideline was assessed using a widely accepted screening measure. Socioeconomic status, immigration background and residential area were assessed using a parent questionnaire.
Results
Overall, 13.1% of girls and 17.4% of boys complied with the national guideline of 60 minutes of moderate-to-vigorous PA daily. While compliance was significantly lower in older participants of both gender groups, the steepest decrease in compliance was observed for age groups around the transition time from primary to secondary school. Logistic regression revealed that socioeconomic status and a migration background were significant predictors for compliance in girls and residential area for compliance in boys.
Conclusions
Programs and policy action addressing the problem of decreasing compliance with PA guideline with increasing age are warranted. The transition from primary school to secondary school seems to be a critical stage in life with respect to PA behaviour. Therefore, specific interventions should aim at restructuring and reorganising their daily and physical activities during this transition.
doi:10.1186/1471-2458-12-714
PMCID: PMC3489607  PMID: 22935245
Physical activity guideline; Socio-demographic; Children; Adolescents; Compliance
6.  Measuring Coverage in MNCH: A Prospective Validation Study in Pakistan and Bangladesh on Measuring Correct Treatment of Childhood Pneumonia 
PLoS Medicine  2013;10(5):e1001422.
Background
Antibiotic treatment for pneumonia as measured by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) is a key indicator for tracking progress in achieving Millennium Development Goal 4. Concerns about the validity of this indicator led us to perform an evaluation in urban and rural settings in Pakistan and Bangladesh.
Methods and Findings
Caregivers of 950 children under 5 y with pneumonia and 980 with “no pneumonia” were identified in urban and rural settings and allocated for DHS/MICS questions 2 or 4 wk later. Study physicians assigned a diagnosis of pneumonia as reference standard; the predictive ability of DHS/MICS questions and additional measurement tools to identify pneumonia versus non-pneumonia cases was evaluated.
Results at both sites showed suboptimal discriminative power, with no difference between 2- or 4-wk recall. Individual patterns of sensitivity and specificity varied substantially across study sites (sensitivity 66.9% and 45.5%, and specificity 68.8% and 69.5%, for DHS in Pakistan and Bangladesh, respectively). Prescribed antibiotics for pneumonia were correctly recalled by about two-thirds of caregivers using DHS questions, increasing to 72% and 82% in Pakistan and Bangladesh, respectively, using a drug chart and detailed enquiry.
Conclusions
Monitoring antibiotic treatment of pneumonia is essential for national and global programs. Current (DHS/MICS questions) and proposed new (video and pneumonia score) methods of identifying pneumonia based on maternal recall discriminate poorly between pneumonia and children with cough. Furthermore, these methods have a low yield to identify children who have true pneumonia. Reported antibiotic treatment rates among these children are therefore not a valid proxy indicator of pneumonia treatment rates. These results have important implications for program monitoring and suggest that data in its current format from DHS/MICS surveys should not be used for the purpose of monitoring antibiotic treatment rates in children with pneumonia at the present time.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Pneumonia is a major cause of death in children younger than five years across the globe, with approximately 1.2 million children younger than five years dying from pneumonia every year. Pneumonia can be caused by bacteria, fungi, or viruses. It is possible to effectively treat bacterial pneumonia with appropriate antibiotics; however, only about 30% of children receive the antibiotic treatment they need. The Millennium Development Goals (MDGs) are eight international development goals that were established in 2000. The fourth goal (MDG 4) aims to reduce child mortality, specifically, to reduce the under-five mortality rate by two-thirds, between 1990 and 2015. Given that approximately 18% of all deaths in children under five are caused by pneumonia, providing universal coverage with effective treatments for pneumonia is an important part of MDG 4.
To ensure that MDG 4 targets are met, it is important to measure progress in providing effective treatments. For pneumonia, one of the key indicators for measuring progress is the proportion of children with pneumonia in a population who receive antibiotic treatment, also known as the antibiotic treatment rate. The antibiotic treatment rate is often measured using surveys, such as the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), which collect nationally representative data about populations and health in developing countries.
Why Was This Study Done?
Concerns have been raised about whether information collected from DHS and MICS is able to accurately identify cases of pneumonia. In a clinical setting, pneumonia is typically diagnosed based on a combination of physical symptoms, including coughing, rapid breathing, or difficulty breathing, and a chest X-ray. The surveys rely on information collected from interviews of mothers and primary caregivers using structured questions about whether the child has experienced physical symptoms in the past two weeks and whether these were chest-related. The DHS survey labels this condition as “symptoms of acute respiratory infection,” while the MICS survey uses the term “suspected pneumonia.” Thus, these surveys provide a proxy measure for pneumonia that is limited by the reliance on the recall of symptoms by the mother or caregiver. Here the researchers have evaluated the use of these surveys to discriminate physician-diagnosed pneumonia and to provide accurate recall of antibiotic treatment in urban and rural settings in Pakistan and Bangladesh.
What Did the Researchers Do and Find?
The researchers identified caregivers of 950 children under five years with pneumonia and 980 who had a cough or cold but did not have pneumonia from urban and rural settings in Pakistan and Bangladesh. Cases of pneumonia were identified based on a physician diagnosis using World Health Organization guidelines. They randomly assigned caregivers to be interviewed using DHS and MICS questions with either a two- or four-week recall period. They then assessed how well the DHS and MICS questions were able to accurately diagnose pneumonia and accurately recall antibiotic use. In addition, they asked caregivers to complete a pneumonia score questionnaire and showed them a video tool showing children with and without pneumonia, as well as a medication drug chart, to determine if these alternative measures improved the accuracy of pneumonia diagnosis or recall of antibiotic use. They found that both surveys, the pneumonia score, and the video tool had poor ability to discriminate between children with and without physician-diagnosed pneumonia, and there were no differences between using two- or four-week recall. The sensitivity (proportion of pneumonia cases that were correctly identified) ranged from 23% to 72%, and the specificity (the proportion of “no pneumonia” cases that were correctly identified) ranged from 53% to 83%, depending on the setting. They also observed that prescribed antibiotics for pneumonia were correctly recalled by about two-thirds of caregivers using DHS questions, and this increased to about three-quarters of caregivers when using a drug chart and detailed enquiry.
What Do These Findings Mean?
The findings of this study suggest that the current use of questions from DHS and MICS based on mother or caregiver recall are not sufficient for accurately identifying pneumonia and antibiotic use in children. Because these surveys have poor ability to identify children who have true pneumonia, reported antibiotic treatment rates for children with pneumonia based on data from these surveys may not be accurate, and these surveys should not be used to monitor treatment rates. These findings should be interpreted cautiously, given the relatively high rate of loss to follow-up and delayed follow-up in some of the children and because some of the settings in this study may not be similar to other low-income settings.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001422.
More information is available on the United Nations goal to reduce child mortality (MDG 4)
The World Health Organization provides information on pneumonia, its impact on children, and the global action plan for prevention and control of pneumonia
More information is available on Demographic and Health Surveys and Multiple Indicator Cluster Surveys
KidsHealth, a resource maintained by the Nemours Foundation (a not-for-profit organization for children's health) provides information for parents on pneumonia (in English and Spanish)
MedlinePlus provides links to additional information on pneumonia (in English and Spanish)
doi:10.1371/journal.pmed.1001422
PMCID: PMC3646205  PMID: 23667339
7.  Agreement between parent and child report on parental practices regarding dietary, physical activity and sedentary behaviours: the ENERGY cross-sectional survey 
BMC Public Health  2014;14(1):918.
Background
Parents and their parenting practices play an important role in shaping their children’s environment and energy-balance related behaviours (EBRBs). Measurement of parenting practices can be parent- or child-informed, however not much is known about agreement between parent and child perspectives. This study aimed to assess agreement between parent and child reports on parental practices regarding EBRBs across different countries in Europe and to identify correlates of agreement.
Methods
Within the ENERGY-project, a cross-sectional survey was conducted among 10–12 year old children and their parents in eight European countries. Both children and parents filled in a questionnaire on 14 parental practices regarding five different EBRBs (i.e. soft drink, fruit juice and breakfast consumption, sports activity and watching TV) and socio-demographic characteristics. Children’s anthropometric measurements were taken at school. We calculated percentages of agreement between children and their parents and weighted kappa statistics (for ordinal variables) per practice and country and assessed factors associated with agreement using multilevel linear regression.
Results
Reports of 6425 children and their parents were available for analysis. Overall mean agreement between parent and child reports was 43% and varied little among countries. The lowest agreement was found for questions assessing joint parent–child activities, such as sports (27%; Kappa (κ) = 0.14) or watching TV (30%;κ = 0.17), and for parental allowance of the child to have soft drinks (32%;κ = 0.24) or fruit juices (32%;κ = 0.19), or to watch TV (27%;κ = 0.17). Having breakfast products available at home or having a TV in the child’s bedroom were the only practices with moderate to good agreement (>60%;κ = 0.06 and 0.77, respectively). In general, agreement was lower for boys, younger children, younger parents, parents with less than 14 years of education, single parents, parents with a higher self-reported body mass index and parents who perceived their child to be underweight.
Conclusions
Parents and children perceive parental practices regarding dietary, physical activity and sedentary behaviours differently in all parts of Europe, with considerable variation across specific practices and countries. Therefore, future studies should assess both, parents and children’s view on parental practices.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-918) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-918
PMCID: PMC4169834  PMID: 25190541
Children; Parent; Parenting; Questionnaire; Inter-observer agreement; Inter-observer variability; Health behaviour; Overweight
8.  Maternal asthma, premature birth, and the risk of respiratory morbidity in schoolchildren in Merseyside. 
Thorax  1995;50(5):525-530.
BACKGROUND--A study was carried out to analyse the impact of maternal asthma on the risk of preterm delivery and the contribution of preterm delivery to the development of childhood asthma. METHODS--Two cross sectional community studies of 1872 children (5-11 years) in 1991 and 3746 children in 1993 were performed. A respiratory health questionnaire was distributed throughout 15 schools in Merseyside and completed by the parents of the children. RESULTS--Asthmatic mothers were more likely to have a preterm delivery than non-asthmatic mothers (odds ratio (OR) 1.49; 95% CI 1.10 to 2.02). Smoking was a separate risk factor for preterm delivery (OR 1.35; 95% CI 1.10 to 1.65). Asthmatic mothers did not have an increased risk of delivering small, growth retarded babies. Maternal asthma, paternal asthma, and premature birth, in that order, increased the risk of later childhood respiratory morbidity (OR 3.13, 95% CI 2.36 to 4.16; 2.23, 95% CI 1.62 to 3.05; 1.40, 95% CI 1.10 to 1.79). Conversely, babies who were small for gestational age appeared less likely to develop doctor diagnosed asthma or the symptom triad of cough, wheeze, and breathlessness in childhood, although this was not statistically significant (OR 0.63, 95% CI 0.28 to 1.41). CONCLUSIONS--Maternal smoking during pregnancy and maternal asthma are independent risk factors associated with preterm delivery. Asthma in mothers predisposes to preterm delivery but not fetal growth retardation. Preterm birth, but not growth retardation, predisposes the child to the development of subsequent asthma.
PMCID: PMC1021223  PMID: 7597666
9.  Can differences in medical drug compliance between European countries be explained by social factors: analyses based on data from the European Social Survey, round 2 
BMC Public Health  2009;9:145.
Background
Non-compliance with medication is a major health problem. Cultural differences may explain different compliance patterns. The size of the compliance burden and the impact of socio-demographic and socio-economic status within and across countries in Europe have, however, never been analysed in one survey. The aim of this study was to analyse 1) medical drug compliance in different European countries with respect to socio-demographic and socio-economic factors, and to examine 2) whether cross-national differences could be explained by these factors.
Methods
A multi-country interview survey European Social Survey, Round 2 was conducted in 2004/05 comprising questions about compliance with last prescribed drug. Non-compliance was classified as primary and secondary, depending whether the drug was purchased or not. Statistical weighting allowed for adjustment for national differences in sample mechanisms. A multiple imputation strategy was used to compensate for missing values. The analytical approach included multivariate and multilevel analyses.
Results
The survey comprised 45,678 participants. Response rate was 62.5% (range 43.6–79.1%). Reported compliance was generally high (82%) but the pattern of non-compliance showed large variation between countries. Some 3.2% did not purchase the most recently prescribed medicine, and 13.6% did not take the medicine as prescribed. Multiple regression analyses showed that each variable had very different and in some cases opposite impact on compliance within countries. The multilevel analysis showed that the variation between countries did not change significantly when adjusted for increasing numbers of covariates.
Conclusion
Reported compliance was generally high but showed wide variation between countries. Cross-national differences could, however, not be explained by the socio-demographic and socio-economic variables measured.
doi:10.1186/1471-2458-9-145
PMCID: PMC2687449  PMID: 19445714
10.  Parental Gentle Guidance and Children's Compliance Within the Family: A Replication Study 
This study examined the link between young children's compliance and parental gentle guidance from a within-family perspective. Observational data from 57 families (mothers, fathers, and two siblings) participating in a family clean-up session were used to replicate earlier findings reported by Volling, Blandon, and Gorvine (2006). Several of the results were replicated with our older sample. Older siblings used more committed compliance and less passive noncompliance than their younger siblings. Mothers used more gentle guidance than fathers, but no differences were found in their parenting across siblings. Maternal and paternal gentle guidance interacted to explain younger siblings' committed compliance to the father and older siblings' situational compliance. For older siblings' committed compliance and both siblings' passive noncompliance, it was the direct effect of parental gentle guidance that was important. Differential parental gentle guidance appears to negatively impact older siblings' compliance. Results underscore the need to explore within-family processes in order to understand children's early compliance and internalization.
doi:10.1037/0893-3200.22.3.355
PMCID: PMC2486495  PMID: 18540764
children's compliance and passive noncompliance; internalization; parenting; within-family processes
11.  Micro-level economic factors and incentives in Children’s energy balance related behaviours - findings from the ENERGY European cross-section questionnaire survey 
Background
To date, most research on obesogenic environments facing school children has focused on physical and socio-cultural environments. The role of economic factors has been investigated to a much lesser extent. Our objective was to explore the association of micro-level economic factors and incentives with sports activities and intake of soft drinks and fruit juice in 10-12 year-old school children across Europe, and to explore price sensitivity in children’s soft drink consumption and correlates of this price sensitivity.
Methods
Data for the study originate from a cross-sectional survey undertaken in seven European countries (Belgium, Greece, Hungary, Netherlands, Norway, Slovenia and Spain) in 2010 among 10-12 year-old school children and their parents. In total, 7234 child questionnaires and 6002 parent questionnaires were completed. The child questionnaire included questions addressing self-reported weekly intake of soft drinks and fruit juices and time spent on sports activities, perception of parental support for sports activities, use of pocket money for soft drinks and perceived price responsiveness. Parent questionnaires included questions addressing the role of budget and price considerations in decisions regarding children’s sports activities, soft drink consumption, home practices and rules and socio-demographic background variables. Data were analysed using multiple linear regression and discrete-choice (ordered probit) modelling.
Results
Economic factors were found to be associated with children’s sports participation and sugary drink consumption, explaining 27% of the variation in time for sports activities, and 27% and 12% of the variation in the children’s soft drink and juice consumption, respectively. Parents’ financial support was found to be an important correlate (Beta =0.419) of children’s sports activities. Children’s pocket money was a strong correlate (Beta =21.034) of soft drink consumption. The majority of the responding children reported to expect that significantly higher prices of soft drinks would lead them to buy less soft drinks with their own pocket money, but a majority of parents did not expect higher soft drink prices to reduce their children’s soft drink consumption.
Conclusions
We conclude that economic factors, especially parents’ financial support and amount of pocket money, appear to be of importance for children’s sports participation and soft drink consumption, respectively.
doi:10.1186/1479-5868-9-136
PMCID: PMC3514146  PMID: 23171289
Children; Obesogenic environment; Economic incentives; Sports activity; Soft drinks; Price responsiveness
12.  Prevalence of attention-deficit/hyperactivity disorder (ADHD) symptoms in preschool children: discrepancy between parent and teacher evaluations 
Objective
Clarifying the characteristics of attention-deficit/hyperactivity disorder (ADHD) symptoms in childhood is important for the prevention and management of this disorder. The purpose of this study was to determine the prevalence of ADHD symptoms in Japanese preschool children based on evaluations performed by parents or teachers.
Methods
A questionnaire survey was performed to evaluate the estimated prevalence of ADHD symptoms in preschool children in Niigata City, Japan. The first survey, conducted in 2003, involved an evaluation of ADHD symptoms by their school teachers. The second survey, conducted in 2006, involved an evaluation of the symptoms by parents. The teacher survey included 9,956 children, and the parent survey included 7,566 children. Parents and teachers assessed ADHD symptoms in children using a 14-item questionnaire based on DSM-III-R. Children with a score of 8 or higher were classified as having ADHD symptoms.
Results
The overall prevalence of ADHD symptoms was 2,349/7,566 (31.1%) in the parent survey and 431/9,956 (4.3%) in the teacher survey, with a prevalence ratio of 7.2 (95% CI: 6.5–7.9). Likelihood ratio test indicated that variables significantly associated with the presence of ADHD symptoms were gender, age, school type, interaction between gender and observer, and interaction between school type and observer (each with P < 0.0001).
Conclusions
The large difference between the estimated prevalence of ADHD symptoms in Japanese preschool children from teacher and parent surveys suggests that compared to teachers, parents consider their children’s symptoms much more serious. Thus, parental evaluation of ADHD symptoms using DSM criteria may be inappropriate for ADHD screening.
doi:10.1007/s12199-008-0075-4
PMCID: PMC2684776  PMID: 19568859
Attention-deficit/hyperactivity disorder (ADHD); Epidemiology; Japan; Preschool children; Prevalence
13.  Effects of phone versus mail survey methods on the measurement of health-related quality of life and emotional and behavioural problems in adolescents 
BMC Public Health  2009;9:491.
Background
Telephone interviews have become established as an alternative to traditional mail surveys for collecting epidemiological data in public health research. However, the use of telephone and mail surveys raises the question of to what extent the results of different data collection methods deviate from one another. We therefore set out to study possible differences in using telephone and mail survey methods to measure health-related quality of life and emotional and behavioural problems in children and adolescents.
Methods
A total of 1700 German children aged 8-18 years and their parents were interviewed randomly either by telephone or by mail. Health-related Quality of Life (HRQoL) and mental health problems (MHP) were assessed using the KINDL-R Quality of Life instrument and the Strengths and Difficulties Questionnaire (SDQ) children's self-report and parent proxy report versions. Mean Differences ("d" effect size) and differences in Cronbach alpha were examined across modes of administration. Pearson correlation between children's and parents' scores was calculated within a multi-trait-multi-method (MTMM) analysis and compared across survey modes using Fisher-Z transformation.
Results
Telephone and mail survey methods resulted in similar completion rates and similar socio-demographic and socio-economic makeups of the samples. Telephone methods resulted in more positive self- and parent proxy reports of children's HRQoL (SMD ≤ 0.27) and MHP (SMD ≤ 0.32) on many scales. For the phone administered KINDL, lower Cronbach alpha values (self/proxy Total: 0.79/0.84) were observed (mail survey self/proxy Total: 0.84/0.87). KINDL MTMM results were weaker for the phone surveys: mono-trait-multi-method mean r = 0.31 (mail: r = 0.45); multi-trait-mono-method mean (self/parents) r = 0.29/0.36 (mail: r = 0.34/0.40); multi-trait-multi-method mean r = 0.14 (mail: r = 0.21). Weaker MTMM results were also observed for the phone administered SDQ: mono-trait-multi-method mean r = 0.32 (mail: r = 0.40); multi-trait-mono-method mean (self/parents) r = 0.24/0.30 (mail: r = 0.20/0.32); multi-trait-multi-method mean r = 0.14 (mail = 0.14). The SDQ classification into borderline and abnormal for some scales was affected by the method (OR = 0.36-1.55).
Conclusions
The observed differences between phone and mail surveys are small but should be regarded as relevant in certain settings. Therefore, while both methods are valid, some changes are necessary. The weaker reliability and MTMM validity associated with phone methods necessitates improved phone adaptations of paper and pencil questionnaires. The effects of phone versus mail survey modes are partly different across constructs/measures.
doi:10.1186/1471-2458-9-491
PMCID: PMC2809066  PMID: 20042099
14.  Polio Eradication–Lessons from the Past and Future Perspective 
Background: India has recently achieved the “Polio free status” by WHO with stringent efforts of the Health Ministry to control its spread. However, we should not forget the lessons learnt from the failure of National malaria eradication Programme and National Tuberculosis control Programme which creates a need to assess the probable barriers for the various National Health Programmes. The present article presents an overview of the Polio Eradication programme in India highlighting the lessons learnt from the past. Also, it evaluates the reality behind full participation of Pulse Polio Programme.
Materials and Methods: The study results of a cross-sectional survey conducted with an aim to assess the probable reasons and barriers behind non compliance of Pulse Polio Programme among parents of children (1-5 yr of age) of Modinagar area have also been discussed. The survey instrument was a structured, 10 item, closed ended questionnaire.
Statistical analysis used: Chi-square test was used to analyze the difference between proportions of individual responses for each question and multiple logistic regression was used to assess relation between socio demographic parameter and absence from Polio Ravivaar.
Results: The study reveals a surprising 68% attendance of Pulse Polio programme which is far behind the desired goal. Most of the parents who did not attend polio ravivaar considered that there was no need for the repetition of Polio vaccine (76.9%) followed by their fear that the vaccine might get contaminated during transportation (74.5%). A significant positive association was found between older age group of the eligible children (4-5 yr, O.R.1.52), female gender, illiterate parents, distance of more than one km from residence to vaccination and lack of source of information (O.R. 1.47).
Conclusion: Efforts should be done to investigate the probable reasons behind non compliance for various immunization programmes to analyse the current situation in detail and formulate appropriate programs for coming years so that the efforts so far don’t go in vain and we secure a healthy Polio free nation for our future generations.
doi:10.7860/JCDR/2014/8383.4621
PMCID: PMC4149146  PMID: 25177640
Immunization; India; Non compliance; Polio eradication; Pulse polio programme; Perceived barriers
15.  Secular trends in fruit intake among Danish schoolchildren, 1988 to 2006: Changing habits or methodological artefacts? 
Background
Intermittent monitoring of fruit and vegetable intake at the population level is essential for the evaluation and planning of national dietary interventions. Yet, only a limited number of studies on time trends in fruit and vegetable intake among children and adolescents have been published internationally. In Denmark, national comprehensive campaigns to enhance fruit and vegetable consumption were initiated in 2001. This paper describes secular trends in fruit intake among Danish adolescents by six comparable school surveys from 1988 to 2006. The paper demonstrates and discusses the consequences of measurement changes introduced in long-term trend analyses.
Methods
We used Danish data from the international Health Behaviour in School-aged Children (HBSC) study collected in 1988, 1991, 1994, 1998, 2002 and 2006. Analyses were conducted on comparable questionnaire-based data from students aged 11, 13 and 15 total (n = 23,871) from a random sample of schools. Data on fruit intake were measured by a food frequency questionnaire. Due to changes in number of response categories beween surveys, different cut-points were analysed.
Results
The prevalence of students eating fruit at least once daily ranged from 78.3% among 13-year-old girls in 1988 to 17.3% among 15-year-old boys in 2002. Based on the six data collections, analyses of trends showed a significant decrease in prevalence of students eating fruit at least once daily from 1988 to 2002 (all p-values < 0.0001). In all age and gender groups, a significant increase in intake occurred between 2002 and 2006 (all p-values < 0.0065). Analyses of alternative cut-points revealed similar results.
Conclusion
Fruit consumption among Danish schoolchildren decreased from 1988 to 2002 with an increase since 2002. We suggest that the increase may be attributable to a nation-wide initiative conducted in Denmark since 2001 to increase the intake of fruit and vegetables in the population. Still, the results imply that a substantial proportion of Danish schoolchildren do not meet the nationally recommended daily intake of fruit. Our analyses indicate that the observed trends are not solely caused by methodological biases related to changes in measurements.
doi:10.1186/1479-5868-5-6
PMCID: PMC2267207  PMID: 18237390
16.  Evaluation of the Compliance, Acceptance, and Usability of a Web-Based eHealth Intervention for Parents of Children With Infantile Hemangiomas: Usability Study 
JMIR Research Protocols  2013;2(2):e54.
Background
Infantile hemangiomas (IH) are common benign vascular tumors in children. Recognition and timely referral of high risk IH to specialized centers is important. This might be achieved by involving parents in the care for IH by means of an eHealth intervention.
Objective
The objective of our study was to evaluate parent compliance, acceptance, and usability of an open access, Web-based eHealth intervention (including e-learning and e-consult) designed to increase parents’ knowledge and (risk) evaluation of IH.
Methods
A cross-sectional study of parents who completed the eHealth intervention between October 2010 and November 2012 was carried out. All parents were sent a study questionnaire. Questions to evaluate compliance (to the advice given by a dermatologist during e-consultation) were asked. Acceptance and usability were evaluated by using the modified Technology Acceptance Model.
Results
A total of 224 parents completed the eHealth intervention and received the questionnaire, 135/224 parents responded (response rate was 60.3%). There were 128/135 questionnaires that were completed and included. A total of 110/128 (85.9%) parents were compliant to the advice of the dermatologist. There were 116.8/128 (91.3%) that perceived the eHealth intervention as useful and almost all parents (98.4%, 126/128) found the information in the e-learning clear. There were 29/128 (22.7%) that experienced technical problems. The majority of the parents (94.5%, 121/128) found the eHealth intervention reliable and most of them (98.4%, 126/128) would recommend the eHealth intervention to other parents. Noncompliant parents judged the eHealth intervention significantly less reliable compared to compliant parents (71%, 10/14 versus 97.3%, 107/110; P=.003).
Conclusions
Parents of children with an IH showed a high compliance (85.9%, 110/128) to the advice of the dermatologist given via our Web-based eHealth intervention. This high compliance might be positively influenced by the good acceptance and usability of the eHealth intervention and might result in timely presentation and treatment of children with high risk IH in specialized centers.
doi:10.2196/resprot.2897
PMCID: PMC3875905  PMID: 24345450
eHealth; e-learning; Internet; compliance; acceptance; usability; dermatology; optimizing care; infantile hemangioma; child
17.  Preschool children's health and its association with parental education and individual living conditions in East and West Germany 
BMC Public Health  2006;6:312.
Background
Social inequalities in health exist globally and are a major public health concern. This study focus on a systematic investigation into the associations between health indicators, living conditions and parental educational level as indicator of the social status of 6-year-old children living in West and East Germany in the decade after re-unification. Explanations of observed associations between parental education and health indicators were examined.
Methods
All boys and girls entering elementary school and living in predefined areas of East and West Germany were invited to participate in a series of cross-sectional surveys conducted between 1991 and 2000. Data of 28,888 German children with information on parental education were included in the analysis. Information about educational level of the parents, individual living conditions, symptoms and diagnoses of infectious diseases and allergies were taken from questionnaire. At the day of investigation, atopic eczema was diagnosed by dermatologists, blood was taken for the determination of allergen-specific immuno-globulin E, height and weight was measured and lung function tests were done in subgroups. Regression analysis was applied to investigate the associations between the health indicators and parental educational level as well as the child's living conditions. Gender, urban/rural residency and year of survey were used to control for confounding.
Results
Average response was 83% in East Germany and 71% in West Germany. Strong associations between health indicators and parental education were observed. Higher educated parents reported more diagnoses and symptoms than less educated. Children of higher educated parents were also more often sensitized against grass pollen or house dust mites, but had higher birth weights, lower airway resistance and were less overweight at the age of six. Furthermore, most of the health indicators were significantly associated with one or more living conditions such as living as a single child, unfavourable indoor air, damp housing condition, maternal smoking during pregnancy or living near a busy road. The total lung capacity and the prevalence of an atopic eczema at the day of investigation were the only health indicators those did not show associations with any of the predictor variables.
Conclusion
Despite large differences in living conditions and evidence that some poor health outcomes were directly associated with poor living conditions, only few indicators demonstrated poorer health in social disadvantaged children. These were in both parts of Germany increased levels of overweight, higher airway resistance and, in East Germany only, reduced height in children with lower educated parents compared to those of higher education. In both East and West Germany, higher prevalence of airway symptoms was associated with a damp housing condition, and lower birth weight, reduced height and increased airway resistance at the age of six were associated with maternal smoking during pregnancy. The latter explained to a large extent the difference in birth weight and airway resistance between the educational groups.
doi:10.1186/1471-2458-6-312
PMCID: PMC1769487  PMID: 17194300
18.  Nasal saline irrigation in preschool children: a survey of attitudes and prescribing habits of primary care pediatricians working in northern Italy 
Background
It has been shown that nasal saline irrigation (NSI) alone can be effective in children with infectious and/or allergic respiratory problems, but no study has assessed the awareness or clinical use of NSI among practising pediatricians. The main aim of this study was to evaluate the use of NSI in pre-school children by primary care pediatricians working in northern Italy.
Methods
Nine hundred randomly selected National Health Service primary care pediatricians with an e-mail address were sent an e-mail asking whether they were willing to respond to a questionnaire regarding the use of NSI. The 870 who answered positively were sent an anonymous questionnaire by post and e-mail that had 17 multiple-choice items.
Results
Completed questionnaires were received from 860 of the 870 primary care pediatricians (98.8%). NSI was used by almost all the respondents (99.3%), although with significant differences in frequency. It was considered both a prophylactic and a therapeutic measure by most of the respondents (60.3%), who prescribed it every day for healthy children and more frequently when they were ill. Most of the primary care pediatricians (87%) indicated an isotonic solution as the preferred solution, and the most frequently recommended administration devices were a nasal spray (67.7%) and bulb syringe (20.6%). Most of the pediatricians (75.6%) convinced parents to use NSI by explaining it could have various beneficial effects, and two-thirds (527/854; 61.7%) thought that most of the parents agreed about the importance of NSI. Analysis of possible associations between NSI prescribing behaviour and the demographic data revealed an associations with age and gender, with pediatricians aged <50 years prescribing NSI more frequently than their older counterparts (p < 0.01), and females prescribing NSI more frequently than males (p < 0.01).
Conclusions
In Northern Italy, most primary care pediatricians prescribe NSI for both the prophylaxis and therapy of upper respiratory tract problems in pre-school children. However, many aspects of the procedure are not clarified, and this reduces parental compliance. Given the medical and economic advantages of NSI, this situation should be changed as soon as possible.
doi:10.1186/1824-7288-40-47
PMCID: PMC4041066  PMID: 24887239
Isotonic saline solution; Hypertonic saline solution; Nasal saline irrigation; Nasal spray; Respiratory tract infection
19.  A cross-sectional survey of compliance with national guidance for alcohol consumption by children: measuring risk factors, protective factors and social norms for excessive and unsupervised drinking 
BMC Public Health  2010;10:547.
Background
The Chief Medical Officer for England has developed the first guidance in England and some of the first internationally on alcohol consumption by children. Using the most recent iteration of a large biennial survey of schoolchildren we measure the extent to which young people's drinking fell within the guidelines just prior to their introduction and the characteristics of individuals whose drinking does not; how alcohol related harms relate to compliance; and risk factors associated with behaving outside of the guidance.
Methods
A cross-sectional survey was conducted utilising a self-completed questionnaire with closed questions. A total of 11,879 schoolchildren, aged 15-16 years, from secondary schools in North West England participated in the study. Data were analysed using chi square and conditional logistic regression.
Results
Alcohol consumption is an established norm by age 15 years (81.3%). Acute alcohol related violence, regretted sex and forgetfulness were experienced by significantly fewer children drinking within the guidance (than outside of it). Over half of drinkers (54.7%) reported routinely drinking more heavily than guidance suggests (here ≥5 drinks/session ≥1 month), or typically drinking unsupervised at home or at a friend's home when parents were absent (57.4%). Both behaviours were common across all deprivation strata. Children with greater expendable incomes were less likely to consume within guidance and reported higher measures for unsupervised, frequent and heavy drinking. Although drinking due to peer pressure was associated with some measures of unsupervised drinking, those reporting that they drank out of boredom were more likely to report risk-related drinking behaviours outside of the guidance.
Conclusions
Successful implementation of guidance on alcohol consumption for children could result in substantial reductions in existing levels of alcohol related harms to young people. However, prolonged social marketing, educational and parental interventions will be required to challenge established social norms in heavy and unsupervised child drinking across all social strata. Policy measures to establish a minimum price for alcohol and provide children with entertaining alternatives to alcohol should also increase compliance with guidance.
doi:10.1186/1471-2458-10-547
PMCID: PMC2945947  PMID: 20831810
20.  Increasing prevalence of asthma diagnosis and symptoms in children is confined to mild symptoms 
Thorax  2001;56(4):312-314.
BACKGROUND—The prevalence of childhood asthma is increasing but few studies have investigated trends in asthma severity. We investigated trends in asthma diagnosis and symptom morbidity between an eight year time period in a paired prevalence study.
METHODS—All children in one single school year aged 8-9 years in the city of Sheffield were given a parent respondent questionnaire in 1991 and 1999 based on questions from the International Survey of Asthma and Allergy in Children (ISAAC). Data were obtained regarding the prevalence of asthma and wheeze and current (12month) prevalences of wheeze attacks, speech limiting wheeze, nocturnal cough and wheeze, and exertional symptoms.
RESULTS—The response rates in 1991 and 1999 were 4580/5321 (85.3%) and 5011/6021 (83.2%), respectively. There were significant increases between the two surveys in the prevalence of asthma ever (19.9% v 29.7%, mean difference 11.9%, 95% confidence interval (CI) 10.16to 13.57, p<0.001), current asthma (10.3% v 13.0%, mean difference 2.7%, 95% CI 1.44 to 4.03, p<0.001), wheeze ever (30.3% v 35.8%, mean difference 5.7%, 95% CI 3.76 to 7.56, p<0.001), wheeze in the previous 12 months (17.0% v 19.4%, mean difference 2.5, 95% CI 0.95 to 4.07, p<0.01), and reporting of medication use (16.9% v 20%, mean difference 3.0%, 95% CI 1.46 to 4.62, p<0.001). There were also significant increases in reported hayfever and eczema diagnoses.
CONCLUSIONS—Diagnostic labelling of asthma and lifetime prevalence of wheeze has increased. The current 12 month point prevalence of wheeze has increased but this is confined to occasional symptoms. The increased medication rate may be responsible for the static prevalence of severe asthma symptoms. The significant proportion of children receiving medication but reporting no asthma symptoms identified from our 1999 survey suggests that some children are being inappropriately treated or overtreated.


doi:10.1136/thorax.56.4.312
PMCID: PMC1746019  PMID: 11254824
21.  Parents' accounts of wheeze and asthma related symptoms: a qualitative study 
Archives of Disease in Childhood  2002;87(2):131-134.
Aims: To examine parents' accounts of how they recognise and judge respiratory symptoms in children, and to investigate their interpretations of respiratory survey questions about wheeze, shortness of breath, and cough.
Methods: Qualitative study using semistructured interviews. Data were analysed using the constant comparative method. Nineteen parents of children aged under 6 years were recruited from a cohort of parents who had responded to an earlier respiratory symptom survey and from one general practice.
Results: Parents judged respiratory symptoms using a range of cues, including changes in the sound of breathing and changes in appearance and behaviour. Experiential resources and contextual factors played an important role in parents' judgements. Interpretations of questions about respiratory symptoms were varied, particularly in relation to the terms "attacks of wheeze" and "shortness of breath". Parents' descriptions of wheeze differed from descriptions of the sound of wheeze used in some survey questionnaires. Parents drew fine distinctions between different "types" of cough and identified a distinct "asthma" cough.
Conclusions: Attention needs to be given to the complexity of reporting respiratory symptoms in children and to the importance of contextual factors in parents' judgements. We suggest that questions which require parents to report on children's internal feelings or states be avoided. Consideration should be given to providing parents with explicit direction on what cues to attend to or ignore in reporting symptoms, and to clarifying some questions that are currently used in clinical practice and in surveys.
doi:10.1136/adc.87.2.131
PMCID: PMC1719200  PMID: 12138062
22.  Athletic Trainer Perceptions of Life-Work Balance and Parenting Concerns 
Journal of Athletic Training  2013;48(3):416-423.
Context:
Life-work balance may be one reason for retention concerns among athletic trainers (ATs), yet evidence does not exist to support the supposition.
Objective:
To assess the perceptions of ATs regarding life-work balance, specifically on parenting issues.
Design:
Survey.
Setting:
Online survey at www.surveymonkey.com.
Patients or Other Participants:
A random sample of National Athletic Trainers' Association members (N = 9516) received the survey; 20.6% (n = 1962; male = 954, female = 816; age = 37 ± 10 years, experience = 13 ± 9 years) completed any portion of the survey. Most respondents worked in the college/university (34.5%, n = 657 of 1908) and secondary school settings (25.9%, n = 476 of 1908). A majority of participants (50.7%, n = 898 of 1770) were parents.
Intervention(s):
We calculated frequencies and percentages and used Mann-Whitney U tests and Kruskal-Wallis tests to identify the differences between sexes and among job settings on life-work balance measures among parents.
Main Outcome Measures:
The questionnaire included 8 life-work balance items, 7 parenting challenge items, and 3 nonparent items.
Results:
The results indicate that sex and setting significantly affected perceptions about parenting. Males articulated a stronger sense of difficulty in finding balance as a working parent (P < .001; 1.95 ± 1.98). Females felt more strongly than males that managing work and family was stressful (P = .04; 3.86 ± 1.13) and caused burnout (P = .004; 3.50 ± 1.24), and that their energy tended to fall short of their needs (P < .001; 3.74 ± 1.15). The decision not to have children was strongly affected by the work setting (P = .014; 3.37 ± 1.42). Both college/university (4.14 ± 0.85) and secondary school (4.03 ± 0.90) ATs would prefer to spend more time at home, as compared with ATs in other settings (P < .001). College/university ATs (P = .025; 3.17 ± 1.23) felt most strongly that their families were neglected because of work. In none of the settings did ATs feel that their employment settings were particularly tolerant of their parenting responsibilities (P = .027; 1.72 ± 1.97).
Conclusions:
Male and female employees had similar perceptions of life-work balance, but occupational setting may affect these perceptions.
doi:10.4085/1062-6050-48.2.01
PMCID: PMC3655755  PMID: 23675801
life-work integration; professional barriers; retention; sex; employment setting
23.  Pilot study to evaluate ecological momentary assessment of tinnitus 
Ear and Hearing  2012;32(2):179-290.
Objectives
Because audiometric evaluation, symptom histories, questionnaires, and similar standard assessment tools may not adequately sample the effects of chronic tinnitus on day-to-day activities, there is a need for alternative methodological approaches to study the impact of tinnitus on day-to-day life. An innovative methodological approach that has shown great promise in the study of chronic health problems characterized by reported temporal and/or situational variability in symptoms and distress is known as ecological momentary assessment (EMA). EMA involves the real time measurement of states, situational factors, and symptoms by individuals as they go about their day-to-day activities. The objective of this pilot investigation was to explore the feasibility of using EMA methods to examine within- and between-day effects of tinnitus.
Design
This study was conducted in three phases: (1) design and development of an EMA methodology that could be used to assess effects of tinnitus; (2) refinement of the methodology through the use of two focus groups; and (3) field-test the methodology with individuals who experienced bothersome tinnitus. For Phase 3, each of the 24 participants wore, throughout their waking hours for two weeks, a personal digital assistant that produced alerts four times a day. The alerts prompted participants to respond to 19 questions, including nine relating to situational and mood factors, and 10 comprising the Tinnitus Handicap Inventory - Screening version (THI-S). To evaluate for potential reactive effects of performing the EMA protocol, each participant completed the paper-and-pencil version of the full 25-item THI before and after the 2-week EMA period.
Results
Participants responded to the alerts with a 90% compliance rate, providing a total of 1210 completed surveys. At the time of their response, participants indicated they were in their house or apartment (67.7%), alone (50.2%), happy (50%), and calm (54.5%). Across most responses, participants could hear their tinnitus (97%), and the loudness of their tinnitus averaged 4.7 on a 7-point increasing-loudness scale. The mean THI-S index score (out of a possible maximum 40 points for greatest tinnitus severity) was 17.0 (moderate self-perceived tinnitus handicap). Repeated THI-S index scores varied considerably both within and between participants. Mean 25-item THI scores were not significantly different before and after the EMA period, suggesting little reactivity of the EMA.
Conclusions
The high compliance rate, positive feedback from participants, lack of reactivity as a result of performing the EMA protocol, and data collected indicate that EMA methodology is feasible with patients who have tinnitus. Outcome data obtained with this methodology cannot be obtained any other way because retrospective questionnaires cannot capture the day-to-day reactions. This methodology has the potential to provide more in-depth and accurate assessments of patients receiving therapy for tinnitus.
doi:10.1097/AUD.0b013e31822f6740
PMCID: PMC3251738  PMID: 21960147
hearing disorders; tinnitus; outcomes assessment
24.  Adolescents' leisure activities, parental monitoring and cigarette smoking - a cross-sectional study 
Background
Adolescent participation in leisure activities is developmentally beneficial, but certain activities may increase health compromising behaviours, such as tobacco smoking. A limited range of leisure activities has been studied, with little research on out-of-school settings where parental supervision is a potential protective factor. Tobacco smoking is an important, potentially modifiable health determinant, so understanding associations between adolescent leisure activities, parental monitoring, demographic factors and daily smoking may inform preventive strategies. These associations are reported for a New Zealand adolescent sample.
Methods
Randomly selected schools (n = 145) participated in the 2006 Youth In-depth Survey, a national, biennial study of Year 10 students (predominantly 14-15 years). School classes were randomly selected and students completed a self-report questionnaire in class time. Adjustment for clustering at the school level was included in all analyses. Since parental monitoring and demographic variables potentially confound relations between adolescent leisure activities and smoking, variables were screened before multivariable modelling. Given prior indications of demographic differences, gender and ethnic specific regression models were built.
Results and Discussion
Overall, 8.5% of the 3,161 students were daily smokers, including more females (10.5%) than males (6.5%). In gender and ethnic specific multivariate analysis of associations with daily smoking (adjusted for age, school socioeconomic decile rating, leisure activities and ethnicity or gender, respectively), parental monitoring exhibited a consistently protective, dose response effect, although less strongly among Māori. Attending a place of worship and going to the movies were protective for non-Māori, as was watching sports, whereas playing team sport was protective for all, except males. Attending a skate park was a risk factor for females and Māori which demonstrated a strong dose response effect.
Conclusions
There were significant differences in the risk of daily smoking across leisure activities by gender and ethnicity. This reinforces the need to be alert for, and respond to, gender and ethnic differences in the pattern of risk and protective factors. However, given the consistently protective, dose response effect of parental monitoring, our findings confirm that assisting oversight of adolescent leisure activities may be a key component in public health policy and prevention programmes.
doi:10.1186/1747-597X-6-12
PMCID: PMC3118374  PMID: 21645407
25.  Development of a core outcome set for clinical trials in childhood asthma: a survey of clinicians, parents, and young people 
Trials  2012;13:103.
Background
In clinical trials in childhood asthma, outcomes reflecting short-term disease activity are frequently measured, whilst functional status, quality of life (QoL), and long-term treatment effects are rarely assessed. There is also non-uniformity across studies in the selection and measurement of outcomes within these domains. The development of a core outcome set has the potential to reduce heterogeneity between trials, lead to research that is more likely to have measured relevant outcomes, and enhance the value of evidence synthesis by reducing the risk of outcome reporting bias and ensuring that all trials contribute usable information.
Methods
Paediatricians and specialist nurses, identified through the British Paediatric Respiratory Society, completed a two-round Delphi survey. Separate cohorts of parents of children younger than 18 years, recruited in clinics, participated in each round. Young people with asthma, aged at least 13 years, participated in the first round. Outcomes were identified separately for preschool and school-aged children.
We identified outcomes considered important in routine clinical assessment by clinicians and parents/young people. In round 1, 46 clinicians suggested outcomes they considered important when deciding whether to adjust a child’s asthma therapy regime, and 49 parents/young people were asked, using open questions, how they judged whether their child’s (for young people, their own) asthma therapy was appropriate. Two researchers independently classified responses into appropriate, corresponding outcomes.
In round 2, 43 clinicians and 50 parents scored, from 0–4, the importance of each outcome suggested by at least 10 % of round 1 responders and selected the three most important.
Results
The most important outcomes, when making shared decisions about regular therapies for school-aged and preschool children with asthma, were daytime and nocturnal symptoms, exacerbations, QoL, and mortality. Results from parents and clinicians were generally concordant, but parents placed more emphasis on long-term treatment effects.
Conclusions
We have developed a methodology to identify outcomes of most relevance to clinicians, parents, and young people when evaluating regularly administered therapies for asthma. Daytime and nocturnal symptoms, exacerbations, QoL, and mortality are particularly important outcomes that should be measured and reported in all clinical trials of regular therapies for children with asthma.
doi:10.1186/1745-6215-13-103
PMCID: PMC3433381  PMID: 22747787
Asthma; Core outcome set; Delphi; Children; Paediatrics

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