Discrimination and Mental Health in a Representative Sample of African-American and Afro-Caribbean Youth.

BACKGROUND: Racism and discrimination are psychosocial stressors that affect the health of minority populations. While discrimination has been associated with poor mental health, little is known about the relationship between discrimination and mental health outcomes in youth nationally. Furthermore, mental and behavioral health consequences of discrimination may differ in different minority groups. OBJECTIVE: The goal of this study is to determine (1) how common perceptions of discrimination are in a nationally representative sample of African-American (AA) and Afro-Caribbean (AC) teens, (2) the relationship between discrimination and mental health conditions, and (3) whether discrimination has different associations with mental health in AA and AC youth. DESIGN: Cross-sectional comparison study SETTING: National Survey of American Life-Adolescent Supplement, a nationwide sample of African-American and Afro-Caribbean youth drawn from a nationally representative household survey of AA and AC population PARTICIPANTS: One thousand, one hundred and seventy AA and AC youth between 13 and 17 years EXPOSURE: Experiences with discrimination (Everyday Discrimination Scale) MAIN OUTCOMES: Lifetime and past 12-month major depression and anxiety RESULTS: Ninety percent of AA and 87% of AC youth experienced discrimination. Discrimination was significantly associated with lifetime and 12-month major depression and lifetime and 12-month anxiety. There were no differences in the associations between discrimination and mental health between AA and AC youth except for lifetime anxiety: as discrimination increased, the likelihood of lifetime anxiety disorder increased at a higher rate among AC youth compared to AA. CONCLUSIONS: Discrimination is a common psychosocial stressor in African-American and Afro-Caribbean youth. It is associated with poor mental health outcomes. There was no difference in the occurrence of discrimination between African-American and Afro-Caribbean youth or in its mental health consequences.

Keeping the Heat on for Children's Health: A Successful Medical-Legal Partnership Initiative to Prevent Utility Shutoffs in Vulnerable Children.

OBJECTIVE: Energy insecurity may result in adverse consequences for children's health, particularly for children with special health needs or chronic health conditions. We aimed to determine whether a multimodal intervention addressing energy insecurity within the framework of a medical-legal partnership (MLP) resulted in an increase in the provision of certifications of medical need for utility coverage in an inner city academic primary care practice. METHODS: Working within a medical-legal partnership, we standardized criteria for providers approving medical need utility certification requests. We compared prior-year utility certification requests and approvals (pre-intervention) with the intervention year for families who reported energy insecurity on a waiting-room screening questionnaire. RESULTS: Between the first and second years of the study, certification of medical need approvals increased by 65%, preventing utility shut-offs for 396 more families with vulnerable children. CONCLUSIONS: Energy insecurity can be screened for and addressed in a busy urban practice, potentially improving the wellbeing of vulnerable children.

Thirty-day outcomes support implementation of a surgical safety checklist.

BACKGROUND: Thirty-day postoperative complications from unintended harm adversely affect patients and their families and increase institutional health care costs. A surgical checklist is an inexpensive tool that will facilitate effective communication and teamwork. Surgical team training has demonstrated the opportunity for stakeholders to professionally engage one another through leveling of the authority gradient to prevent patient harm. The American College of Surgeons National Surgical Quality Improvement Program database is an outcomes reporting tool capable of validating the use of surgical checklists. STUDY DESIGN: Three 60-minute team training sessions were conducted and participants were oriented to the use of a comprehensive surgical checklist. The surgical team used the checklist for high-risk procedures selected from those analyzed for the American College of Surgeons National Surgical Quality Improvement Program. Trained observers assessed the checklist completion and collected data about perioperative communication and safety-compromising events. RESULTS: Data from the American College of Surgeons National Surgical Quality Improvement Program were compared for 2,079 historical control cases, 246 cases without checklist use, and 73 cases with checklist use. Overall completion of the checklist sections was 97.26%. Comparison of 30-day morbidity demonstrated a statistically significant (p = 0.000) reduction in overall adverse event rates from 23.60% for historical control cases and 15.90% in cases with only team training, to 8.20% in cases with checklist use. CONCLUSIONS: Use of a comprehensive surgical safety checklist and implementation of a structured team training curriculum produced a statistically significant decrease in 30-day morbidity. Adoption of a comprehensive checklist is feasible with team training intervention and can produce measurable improvements in patient outcomes.

Decreasing the local anesthetic volume from 20 to 10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis.

BACKGROUND AND OBJECTIVES: This prospective, randomized, double blind study was designed to determine whether reduction in volume from 20 to 10 mL of ropivacaine 0.5% for ultrasound-guided interscalene block might decrease the incidence of diaphragmatic paresis and preserve pulmonary function. METHOD: Thirty patients scheduled for arthroscopic shoulder surgery were randomized to receive either 10 or 20 mL of ropivacaine 0.5% for interscalene block at the level of the cricoid cartilage. General anesthesia was administered for surgery, and the surgeon infiltrated lidocaine at the port sites. Hemidiaphragmatic excursion and pulmonary function tests were measured before block, 15 mins after block, and at the time of discharge from recovery room. Onset and duration of sensory dermatomal spread, motor block, pain scores, and analgesic consumption were recorded. RESULTS: Hemidiaphragmatic paresis occurred 15 mins after block performance in 14 of 15 patients in each group. At postanesthesia care unit discharge, 13 of 15 patients in each group continued to demonstrate hemidiaphragmatic paresis. Significant reduction of spirometric values(forced vital capacity, forced expiratory volume at 1 sec, and peak expiratory flow) occurred to a similar degree in both groups after block.Sensory dermatomal spread, motor block, pain scores, and analgesic consumption were not significantly different between groups. CONCLUSIONS: Decreasing the volume for interscalene block from 20 to 10 mL did not reduce the incidence of hemidiaphragmatic paresis or impairment in pulmonary function, which persisted at discharge from recovery room. No significant differences in quality or duration of analgesia were observed.

Educational outreach to reduce immunization pain in office settings.

OBJECTIVE: The goal was to examine the impact of a teaching module on immunization pain reduction practices in pediatric offices 1 and 6 months after the intervention. METHODS: Fourteen practices were selected randomly to receive a 1-hour teaching session on immunization pain reduction techniques, and 13 completed the study. Before the intervention, telephone interviews were conducted with parents concerning their children's recent immunization experiences. At 1 and 6 months after the intervention, parents of children who had recent immunizations were interviewed by using the same questionnaires. Clinicians also were surveyed at baseline and at 6 months. RESULTS: A total of 839 telephone interviews and 92 clinician surveys were included. Significant changes from baseline were identified at 1 and 6 months after the intervention. At 1 month, parents were more likely to report receiving information (P = .04), using strategies to reduce pain (P < .01), learning something new (P < .01), using a ShotBlocker (P < .01), using sucrose (P < .01), and having higher levels of satisfaction (P = .015). At 6 months, all rates remained significantly higher than baseline findings (all P < .01) except for satisfaction. Clinician surveys revealed significant increases in the use of longer needles, sucrose, pinwheels, focused breathing, and ShotBlockers at 6 months. CONCLUSIONS: A 1-hour teaching session had measurable effects on the use of pain-reducing strategies at 1 and 6 months after the intervention. This research supports the hypothesis that small-group teaching sessions at the site of care can be associated with changes in practice behaviors.

Perceived racism and discrimination in children and youths: an exploratory study.

Racism may be a factor contributing to poor health and health care disparities in minority children through multiple mechanisms, including effects on psychological and physical wellbeing. Little is known about the experiences of racism that children encounter in their lives. This study describes the occurrences of perceived racism in children, including the settings and contexts in which it occurs. A questionnaire was administered to a convenience sample of urban children (eight to 16 years of age) asking about settings and situations in which they perceived discrimination. Two hundred and seventy-seven children completed the questionnaire; 88 percent ofthe children had at least one experience with racial discrimination, and 11.6 percent had experienced racism in at least half (12) of the 23 situations addressed in the questionnaire. Settings included schools and community contexts, and both peers and adults were perceived to be perpetrators. There were few differences in perceptions of racist episodes among different ethnocultural minority groups. Racism is perceived to be a common occurrence in many minority children's lives. Studies investigating perceptions of racism and how they relate to health disparities need to be conducted.

Perceptions of Racism in Children and Youth (PRaCY): properties of a self-report instrument for research on children's health and development.

Experiences of racial discrimination have been demonstrated to be related to racial and ethnic disparities in mental and physical health and healthcare. There has been little study, however, of the relationship between racism and health in children, and few psychometrically valid and reliable instruments to measure Perceptions of Racism in Children and Youth (PRaCY) exist. This paper reports on the development and testing of such an instrument, the PRaCY. Development of the instrument began with open-ended qualitative interviews, from which a proto-questionnaire was created. The questionnaire gathered information on the prevalence, attribution, emotional responses, and coping responses to 23 situations identified by participants in the qualitative phase. The proto-questionnaire was administered to 277 children between the ages of 8 and 18 years (38% Latino/a, 31% African-American, 19% multiracial/multicultural, 7% West Indian/Caribbean, and 5% Other). Item analysis resulted in two developmentally appropriate 10-item instruments (one for ages 7-13, another for ages 14-18). Internal consistency reliability was strong (alpha = 0.78 for both versions of the instrument). Confirmatory factor analysis demonstrated good fit for both versions (younger-Comparative Fit Index (CFI): 0.967, Root Mean Square Error of Approximation (RMSEA): 0.047; older-CFI: 0.934, RMSEA: 0.056). Differential item functioning analyses demonstrated no group-specific biases in item response. PRaCY scores were appropriately associated with higher depressive symptom scores and elevated anxiety scores in the younger sample. Results indicate that the PRaCY is a valid and reliable instrument that measures perceptions of racism and discrimination in children and youth aged 8-18 from diverse racial/ethnic backgrounds.

Role of pediatric health care professionals in the provision of parenting advice: a qualitative study with mothers from 4 minority ethnocultural groups.

OBJECTIVE: This study's aim was to elicit the perspectives of minority parents on their expectations of pediatric health care providers as a source of advice on "raising their child" and whether they would seek advice from these providers. A secondary aim was to demonstrate the value of qualitative methods for assessing parental attitudes in pediatric research. METHODS: Mothers with children between 3 and 12 years of age who identified themselves as African American, Jamaican, Haitian, or Puerto Rican were recruited from community sites. Audiotaped focus groups were conducted by trained moderators using an interview guide, to obtain the perspectives of the participants regarding the role of pediatric providers in the provision of parenting advice. RESULTS: Ninety-one mothers participated in a total of 20 focus groups, with 4 to 6 discussions per ethnocultural group. The focus groups revealed that, in general, parents do not look to child health care providers for advice on raising their children. The identified themes emphasized the importance of the relationship between providers and families. A few parents had the type of relationship within which the pediatrician already functioned as a provider of parenting advice. Physicians were considered skilled in the maintenance of physical health. The parents expressed a desire to receive more anticipatory guidance on developmental and behavioral stages and milestones. Pediatricians also served specific administrative functions valued by parents. CONCLUSIONS: Minority parents of preschool-aged and school-aged children do not view the primary care provider's role as including the provision of parenting advice. Expectations must be modified to enable health care professionals to function effectively in the role of advisor regarding parenting issues.

Managing anemia in low-income toddlers: barriers, challenges and context in primary care.

Iron-deficiency remains a concern among low-income toddlers in the U.S. This formative study describes how primary care providers serving high-risk 1- to 3-year-old children in an urban ambulatory care setting approach anemia. Data collection included a retrospective review of randomly selected medical records (n=264) and semi-structured interviews with clinicians (n=41). Thirty-eight percent of the children presented with anemia (Hgb < 11.0 g/dl) at least once between 12 and 36 months of age. Just under half of these children were treated for anemia. Follow-up laboratories for iron-treated children were completed within 35 days in 16% of cases (median: 3 months). Interviews identified four key themes (iron-deficiency, communication, poverty, system) running through the two major categories of prevention and treatment. Treatment cut-points were variable. While providers felt clinically comfortable with anemia, they felt burdened and challenged by follow-up. Communication and system barriers weighed most heavily on perceived treatment outcomes.