Effectiveness of a Pediatric Primary Care Intervention to Increase Maternal Folate Use: Results from a Cluster Randomized Controlled Trial.

OBJECTIVE: To assess the impact of provision of folate vitamins and a preconception health intervention on folate use among mothers bringing infants to pediatric primary care. STUDY DESIGN: We conducted a cluster randomized trial in mothers presenting with their infants (<12 months) at 4 urban pediatric practices in the Baltimore, Maryland, metropolitan area. There were 45 clinicians randomized into an intervention group (15-item preconception health screening and counseling and 90-day multivitamin supply) and control group (preconception health and community resource handouts and 90-day multivitamin supply). Participating mothers were enrolled in the study group assigned to their child's clinician. Baseline and 6-month follow-up interviews were performed. The outcome was daily use of folate, multivitamin, and a prenatal vitamin containing folate. Primary independent variables were time of assessment and mother's study group (intervention or control groups). Covariates investigated were mother's and child's age, race/ethnicity, education, marital status, income, insurance status, previous live births, and intention to have a pregnancy in the next 6 months. RESULTS: We enrolled 415 mothers at baseline who were majority African American and low income. Of the 415 enrolled participants, 352 (85%) completed follow-up interviews. Among all participants, daily vitamin intake increased from baseline to 6-month follow-up (33.8% vs 42.6%; P = .016). After adjustment for covariates and clustered design, there was an augmented effect in the intervention vs control group (aOR, 2.04; 95% CI, 1.04-3.98). CONCLUSIONS: Offering vitamins and recommending folate intake to mothers within pediatric practice can increase use. Pediatric practice is an important contact point and context for improving maternal folate use. TRIAL REGISTRATION: ClinicalTrials.govNCT02049554.

Caregiver Health Promotion in Pediatric Primary Care Settings: Results of a National Survey.

OBJECTIVE: To assess practice patterns, barriers, and facilitators related to caregiver health promotion in pediatric primary care settings. STUDY DESIGN: We conducted a mail-based survey of a nationally representative sample of 1000 children's primary care physicians (trained in pediatrics, family medicine, or medicine-pediatrics). We assessed engagement in 6 caregiver health issues (maternal depression, tobacco use, intimate partner violence, family planning, health insurance, and tetanus, diphtheria, and acellular pertussis immunization status) along with barriers and facilitators related to engagement. We used multivariable logistic regression to identify physician and practice correlates of engagement. RESULTS: The response rate was 30%. The majority of respondents (79.3%) regularly addressed at least 3 caregiver health issues during well infant/child visits, most commonly maternal depression, tobacco use, and tetanus, diphtheria, and acellular pertussis immunization immunization status. Screening was the most common activity. In adjusted analyses, pediatricians were less likely to screen for intimate partner violence and family planning compared with other providers. There were no other differences in engagement by physician specialty. Lack of time was the most commonly endorsed barrier (by 85.2% of respondents). Co-location of auxiliary services was the most frequently cited facilitator for the majority of issues. CONCLUSIONS: Children's primary care physicians and their care teams routinely engage in a variety of activities promoting caregiver health, largely independent of training background and despite multiple practice-related barriers. Co-location of auxiliary services could support the efforts of pediatric care teams. Future efforts that investigate care models which address these barriers and facilitators will help to realize the potential of pediatric settings to impact adult health.

Predictors of Weapon-Related Behaviors among African American, Latino, and White Youth.

OBJECTIVE: To identify risk and protective factors for weapon involvement among African American, Latino, and white adolescents. STUDY DESIGN: The National Longitudinal Study of Adolescent to Adult Health is a nationally representative survey of 7th-12th grade students. Predictors at wave 1 and outcome at wave 2 were analyzed. Data were collected in the mid-1990s, when rates of violent crime had been declining. The outcome was a dichotomous measure of weapon-involvement in the past year, created using 3 items (weapon-carrying, pulled gun/knife, shot/stabbed someone). Bivariate and multilevel logistic regression analyses examined associations of individual, peer, family, and community characteristics with weapon involvement; stratified analyses were conducted with African American, Latino, and white subsamples. RESULTS: Emotional distress and substance use were risk factors for all groups. Violence exposure and peer delinquency were risk factors for whites and African Americans. Gun availability in the home was associated with weapon involvement for African Americans only. High educational aspirations were protective for African Americans and Latinos, but higher family connectedness was protective for Latinos only. CONCLUSIONS: Interventions to prevent weapon-related behaviors among African American, Latino, and white adolescents may benefit from addressing emotional distress and substance use. Risk and protective factors vary by race/ethnicity after adjusting for individual, peer, family, and community characteristics. Addressing violence exposure, minimizing the influence of delinquent peers, promoting educational aspirations, and enhancing family connectedness could guide tailoring of violence prevention interventions.

Pediatric Academic Productivity: Pediatric Benchmarks for the h- and g-Indices.

OBJECTIVE: To describe h- and g-indices benchmarks in pediatric subspecialties and general academic pediatrics. Academic productivity is measured increasingly through bibliometrics that derive a statistical enumeration of academic output and impact. The h- and g-indices incorporate the number of publications and citations. Benchmarks for pediatrics have not been reported. STUDY DESIGN: Thirty programs were selected randomly from pediatric residency programs accredited by the Accreditation Council for Graduate Medical Education. The h- and g-indices of department chairs were calculated. For general academic pediatrics, pediatric gastroenterology, and pediatric nephrology, a random sample of 30 programs with fellowships were selected. Within each program, an MD faculty member from each academic rank was selected randomly. Google Scholar via Harzing's Publish or Perish was used to calculate the h-index, g-index, and total manuscripts. Only peer-reviewed and English language publications were included. For Chairs, calculations from Google Scholar were compared with Scopus. RESULTS: For all specialties, the mean h- and g-indices significantly increased with academic rank (all P < .05) with the greatest h-indices among Chairs. The h- and g-indices were not statistically different between specialty groups of the same rank; however, mean rank h-indices had large SDs. The h-index calculation using different bibliographic databases only differed by ±1. CONCLUSION: Mean h-indices increased with academic rank and were not significantly different across the pediatric specialties. Benchmarks for h- and g-indices in pediatrics are provided and may be one measure of academic productivity and impact.

Use of technology with health care providers: perspectives from urban youth.

OBJECTIVE: To evaluate urban youths' use of and access to technology and solicit their opinions about using technology with healthcare providers. STUDY DESIGN: Urban youth (aged 14-24 years) were invited to participate in focus groups in which a trained focus group facilitator used a survey and a structured guide to elicit responses regarding the foregoing objective. All sessions were audiotaped and transcribed. Emergent themes were determined with the assistance of Atlas TI. Survey data were analyzed in SPSS (SPSS Inc, Chicago, Illinois). RESULTS: Eight focus groups including 82 primarily low-income urban African-American adolescents and young adults (mean age, 18.5 years) were completed. The participants reported fairly high access to and use of technology. However, they expressed some concerns regarding the use of technology with healthcare providers. Many worried about the confidentiality of conversations conducted using technology. Face-to-face meetings with a healthcare provider were preferred by most participants, who felt that the information provided would be better tailored to their individual needs and more credible. CONCLUSION: Although urban youth were high users of technology, they expressed reservations about using technology with health care providers. When developing new technology communication and information dissemination strategies, it is critical to understand and address these concerns while involving young people in the research and development process.

Coincident mass extirpation of neotropical amphibians with the emergence of the infectious fungal pathogen Batrachochytrium dendrobatidis.

Amphibians highlight the global biodiversity crisis because ∼40% of all amphibian species are currently in decline. Species have disappeared even in protected habitats (e.g., the enigmatic extinction of the golden toad, Bufo periglenes, from Costa Rica). The emergence of a fungal pathogen, Batrachochytrium dendrobatidis (Bd), has been implicated in a number of declines that have occurred in the last decade, but few studies have been able to test retroactively whether Bd emergence was linked to earlier declines and extinctions. We describe a noninvasive PCR sampling technique that detects Bd in formalin-preserved museum specimens. We detected Bd by PCR in 83-90% (n = 38) of samples that were identified as positive by histology. We examined specimens collected before, during, and after major amphibian decline events at established study sites in southern Mexico, Guatemala, and Costa Rica. A pattern of Bd emergence coincident with decline at these localities is revealed-the absence of Bd over multiple years at all localities followed by the concurrent emergence of Bd in various species at each locality during a period of population decline. The geographical and chronological emergence of Bd at these localities also indicates a southbound spread from southern Mexico in the early 1970s to western Guatemala in the 1980s/1990s and to Monteverde, Costa Rica by 1987. We find evidence of a historical "Bd epidemic wave" that began in Mexico and subsequently spread to Central America. We describe a technique that can be used to screen museum specimens from other amphibian decline sites around the world.

Screening for domestic violence and childhood exposure in families seeking care at an urban pediatric clinic.

In a survey of 133 caregivers in a pediatric clinic, 30 women (23%) disclosed domestic violence, with 2 reporting coercive control but not physical violence. Seventeen women stated that a child had been exposed as well. Domestic violence is not a "private" adult problem; further study of an appropriate pediatric-based screener is needed.

Beliefs about the appropriate age for initiating toilet training: are there racial and socioeconomic differences?

OBJECTIVE: To examine racial and socioeconomic differences in parental beliefs about the appropriate age at which to initiate toilet training. STUDY DESIGN: A cross-sectional survey of 779 parents visiting child health providers in 3 clinical sites in Washington, DC and the surrounding metropolitan area completed a self-report survey. The main outcome variable was parental beliefs about the appropriate age at which to initiate toilet training. Using multiple linear regression, differences in beliefs were assessed in relation to race, family income, parental education, parental age, and age of the oldest and youngest children. RESULTS: Among respondents, parents felt that the average age at which toilet training should be initiated was 20.6 months (+/-7.6 months), with a range of 6 to 48 months. Caucasian parents believed that toilet training should be initiated at a significantly later age (25.4 months) compared with both African-American parents (18.2 months) and parents of other races (19.4 months). In the multiple regression model, factors predicting belief in when to initiate toilet training were Caucasian race and higher income. CONCLUSIONS: Race and income were independent predictors of belief in age at which to initiate toilet training. More research is needed to determine what factors contribute to toilet training practices in diverse populations.