Child restraint headrest and belt routing design features and their association with child passenger behavior and restraint misuse.

OBJECTIVES: Ergonomic design of child restraint systems (CRS) may facilitate optimal travel behavior and crash protection of child passengers during motor vehicle trips. However there have been few studies examining the relationship between CRS design and child passenger travel behavior. The aim of this study was to examine whether associations between CRS design features and child passenger behavior exist during real-world, everyday vehicle trips. METHODS: Video from a naturalistic driving study (NDS) was analyzed in this study. Families drove an instrumented study vehicle for approximately two weeks with at least one child aged between one and eight years traveling in their own forward-facing (FF) CRS or belt positioning booster (BPB). Video for one child passenger was randomly selected from each trip for analysis. Video was coded for five-second epochs at nine time points (5%, 17%, 25%, 30%, 50%, 53%, 75%, 89% and 95% of trip length). Two types of child passenger travel behaviors were identified by manual review of the video and audio recordings: (i) optimal/suboptimal head position and (ii) correct/incorrect use of the internal harness/shoulder belt. Video screenshots were used to characterize CRS design features. Random effects logistic regression models were used to examine the associations between specific CRS design features and the travel behaviors of interest, whilst accounting for clustering of data by child and trip. RESULTS: Suboptimal head position was associated with the absence of a height adjustable headrest and a narrow headrest wing width in FFCRS. Incorrect harness use in a FFCRS was associated with the absence of an adjustable headrest, in addition to headrest features such as wing width and depth. In BPBs, a reduction in suboptimal head position was associated with the absence of a sash belt guide, however no restraint design features were associated with incorrect shoulder belt use. CONCLUSIONS: Some CRS design features may influence undesirable child passenger travel behavior. These early findings support enhanced and user-centric CRS design as a likely important mechanism to improve child passenger safety.

The common characteristics and behaviors of child occupants in motor vehicle travel.

Objective: Child occupant behavior and head position when travelling in child restraint systems (CRS) may have an effect on injury risk in the event of a motor vehicle crash. The current study aimed to describe the common characteristics and behaviors of child occupants during everyday, real-world motor vehicle travel in a sample of Australian families to identify potential safety implications of observed behaviors and head position within the CRS. Methods: Two instrumented study vehicles were used by 42 families for approximately two weeks. Continuous video and audio data were collected across 1,651 trips (over 600 hours). An online survey provided additional parent, familial and child occupant data. The characteristics and behaviors of 72 child occupants (aged 14 months to 9 years) who travelled in a forward-facing CRS (FFCRS) or a belt-positioning booster seat (BS) were observed and recorded by manual review of a sample of the video/audio recordings. One quarter of all trips (n = 414) was randomly selected for coding/analysis and, within each trip, one child occupant was selected who was travelling in a FFCRS or BS. Child occupant behaviors, head position within the FFCRS or BS, and other relevant information was coded for each trip during nine discrete five second intervals or 'epochs' (5%, 17%, 25%, 30%, 50%, 53%, 75%, 89% and 95% of trip duration). Results: In the majority of epochs (74%), child occupants' heads were observed to be 'optimally' positioned within the FFCRS or BS. For more than half of the epochs, child occupants were observed to be: correctly restrained (58%) and involved in an interaction with another vehicle occupant (59%). Bivariate analyses revealed that children travelling in a FFCRS were significantly more likely to be observed to have optimal head positions than those travelling in a BS (78% vs. 62%), χ2 (1) = 86.00, p < 0.001. Child occupants who were observed to be 'correctly' restrained were significantly more likely to be observed to have optimal head positions than those who were observed to be 'incorrectly' restrained (80% vs. 20%), χ2 (1) = 10.33, p < 0.01. Conclusions: This is the first naturalistic driving study (NDS) to specifically explore the factors associated with child occupants' head position when travelling in a CRS. Findings from the current study can be used to inform the positioning of anthropometric test dummies (ATD) in CRS testing, guide improvements to CRS/vehicle design, and develop targeted educational strategies to improve child occupant safety.

An invisible workforce: the neglected role of cleaners in patient safety on maternity units.

Hospital cleaning has been shown to impact on rates of healthcare-associated infections (HCAIs) and good environmental hygiene is critical to quality care, yet those tasked with the role of ensuring a safe and clean environment often go unrecognised as members of the healthcare workforce. Sepsis is a leading cause of maternal and newborn death, a significant proportion of these cases are estimated to be due to HCAIs. Deliveries in health institutions have now reached 75% globally, and in low and middle income countries the corresponding increased pressure on facilities  has impacted both quality of care provided and quality of the birth environment in terms of infection prevention and control (IPC) and HCAIs. The paper discusses the neglected role of health facility cleaners, providing evidence from the literature and from needs assessments conducted by The Soapbox Collaborative and partners in Bangladesh, India, The Gambia and Zanzibar. While not the primary focus of the assessments, common themes emerged consistently pointing to institutional neglect of cleaning and cleaners. The paper argues that low status within facilities, wider societal marginalisation, lack of training, and poor pay and working conditions contribute to the lack of prioritisation placed on health facility environmental hygiene. With increased international attention focused towards health facility water, sanitation and hygiene and a growing focus on IPC, now is the time to address the neglect of this frontline healthcare workforce. We propose that provision of and improved training can enable the recognition of the valuable role cleaning staff play, as well as equipping these staff with the tools required to perform their job to the highest standard. In addition to training, wider systems changes are necessary to establish improvements in environmental hygiene and the role of cleaning staff, including addressing resource availability, supportive supervision, and an increased emphasis on preventative healthcare.

The Water@Birth Study: an exploratory study on the requirements of water for hand hygiene during labour and delivery in low-income countries.

BACKGROUND: Infections acquired during childbirth are one of the leading causes of maternal death; the majority of these deaths occur in low-income settings. Hand hygiene is one of the most effective ways of preventing infection but requires basic resources, such as running water, to be performed. Limited literature on water volume requirements for hand hygiene in healthcare facilities exists despite the importance of this information, particularly in resource-poor settings. AIM: To establish the volume of water required for hand hygiene during childbirth in low-income countries. METHODS: Data was collected in Aberdeen Maternity Hospital (AMH) and Felege Hiwot Referral Hospital, Ethiopia (FHRH), with an average of 14 and 16 deliveries per day respectively. Primary data on hand hygiene opportunities (HHOs) during childbirth were gathered using observational methods, and secondary data gathered from register and case-note reviews. The volume of water required for each HHO (H2O/HHO) was calculated by multiplying flow rate by hand washing time. Estimates of water requirements were derived by calculating the number of HHOs during childbirth and the H2O/HHO. Water requirement estimates from each facility were compared to each other as well as to WHO recommendations. Due to skewed data, Spearman's rho was utilised to explore the relationship between variables. RESULTS: Eleven deliveries were observed in AMH and 20 in FHRH. The number of HHOs was largely determined by the length of labour. Stringently following WHO recommendations lead to a significantly higher number of HHOs than was performed in clinical practice at both sites. Hand washing also occurred for a much shorter time than the WHO recommendation of 40-60 seconds, with an average of 24 seconds in AMH and 25 seconds in FHRH observed. The estimated number of HHOs at sites ranged from 5 to 16 per hour per delivery and water consumption from 21 to 159.6 litres per hour per delivery. Hand hygiene was estimated to require 8937.6 litres and 4838.4 litres per day or 638.4 litres and 302.4 litres per delivery for AMH and FHRH, respectively. CONCLUSIONS: Water requirements are variable due to the nature of childbirth but are not currently met in low-income countries. In terms of performance of hand hygiene, there is a large gap between clinical and recommended practice and thus room for improvement. The volume of water required for hand hygiene has significant implications for water requirements within maternity units, particularly in resource-poor settings. Further research on water requirements is merited to improve the targeting of limited resources.

Frontal and oblique crash tests of HIII 6-year-old child ATD using real-world, observed child passenger postures.

OBJECTIVE: The aim of this study was to evaluate the consequences of frontal and oblique crashes when positioning a Hybrid III (HIII) 6-year-old child anthropometric test device (ATD) using observed child passenger postures from a naturalistic driving study (NDS). METHODS: Five positions for booster-seated children aged 4-7 years were selected, including one reference position according to the FMVSS 213 ATD seating protocol and 4 based on real-world observed child passenger postures from an NDS including 2 user positions with forward tilting torso and 2 that combined both forward and lateral inboard tilting of the torso. Seventeen sled tests were conducted in a mid-sized vehicle body at 64 km/h (European New Car Assessment Programme [Euro NCAP] Offset Deformable Barrier [ODB] pulse), in full frontal and oblique (15°) crash directions. The rear-seated HIII 6-year-old child ATD was restrained on a high-back booster seat. In 10 tests, the booster seat was also attached with a top tether. In the oblique tests, the ATD was positioned on the far side. Three camera views and ATD responses (head, neck, and chest) were analyzed. RESULTS: The shoulder belt slipped off the shoulder in all ATD positions in the oblique test configuration. In full frontal tests, the shoulder belt stayed on the shoulder in 3 out of 9 tests. Head acceleration and neck tension were decreased in the forward leaning positions; however, the total head excursion increased up to 210 mm compared to te reference position, due to belt slip-off and initial forward leaning position. CONCLUSIONS: These results suggest that real-world child passenger postures may contribute to shoulder belt slip-off and increased head excursion, thus increasing the risk of head injury. Restraint system development needs to include a wider range of sitting postures that children may choose, in addition to the specified postures of ATDs in seating test protocols, to ensure robust performance across diverse use cases. In addition, these tests revealed that the child ATD is limited in its ability to mimic real-world child passenger postures. There is a need to develop child human body models that may offer greater flexibility for these types of crash evaluations.

Aligning systems science and community-based participatory research: A case example of the Community Health Advocacy and Research Alliance (CHARA).

Partnered research may help bridge the gap between research and practice. Community-based participatory research (CBPR) supports collaboration between scientific researchers and community members that is designed to improve capacity, enhance trust, and address health disparities. Systems science aims to understand the complex ways human-ecological coupled systems interact and apply knowledge to management practices. Although CBPR and systems science display complementary principles, only a few articles describe synergies between these 2 approaches. In this article, we explore opportunities to utilize concepts from systems science to understand the development, evolution, and sustainability of 1 CBPR partnership: The Community Health Advocacy and Research Alliance (CHARA). Systems science tools may help CHARA and other CBPR partnerships sustain their core identities while co-evolving in conjunction with individual members, community priorities, and a changing healthcare landscape. Our goal is to highlight CHARA as a case for applying the complementary approaches of CBPR and systems science to (1) improve academic/community partnership functioning and sustainability, (2) ensure that research addresses the priorities and needs of end users, and (3) support more timely application of scientific discoveries into routine practice.

Automated recognition of rear seat occupants' head position using Kinect™ 3D point cloud.

INTRODUCTION: Child occupant safety in motor-vehicle crashes is evaluated using Anthropomorphic Test Devices (ATD) seated in optimal positions. However, child occupants often assume suboptimal positions during real-world driving trips. Head impact to the seat back has been identified as one important injury causation scenario for seat belt restrained, head-injured children (Bohman et al., 2011). There is therefore a need to understand the interaction of children with the Child Restraint System to optimize protection. METHOD: Naturalistic driving studies (NDS) will improve understanding of out-of-position (OOP) trends. To quantify OOP positions, an NDS was conducted. Families used a study vehicle for two weeks during their everyday driving trips. The positions of rear-seated child occupants, representing 22 families, were evaluated. The study vehicle - instrumented with data acquisition systems, including Microsoft Kinect™ V1 - recorded rear seat occupants in 1120 driving 26 trips. Three novel analytical methods were used to analyze data. To assess skeletal tracking accuracy, analysts recorded occurrences where Kinect™ exhibited invalid head recognition among a randomly-selected subset (81 trips). Errors included incorrect target detection (e.g., vehicle headrest) or environmental interference (e.g., sunlight). When head data was present, Kinect™ was correct 41% of the time; two other algorithms - filtering for extreme motion, and background subtraction/head-based depth detection are described in this paper and preliminary results are presented. Accuracy estimates were not possible because of their experimental nature and the difficulty to use a ground truth for this large database. This NDS tested methods to quantify the frequency and magnitude of head positions for rear-seated child occupants utilizing Kinect™ motion-tracking. RESULTS: This study's results informed recent ATD sled tests that replicated observed positions (most common and most extreme), and assessed the validity of child occupant protection on these typical CRS uses. SUMMARY: Optimal protection in vehicles requires an understanding of how child occupants use the rear seat space. This study explored the feasibility of using Kinect™ to log positions of rear seated child occupants. Initial analysis used the Kinect™ system's skeleton recognition and two novel analytical algorithms to log head location. PRACTICAL APPLICATIONS: This research will lead to further analysis leveraging Kinect™ raw data - and other NDS data - to quantify the frequency/magnitude of OOP situations, ATD sled tests that replicate observed positions, and advances in the design and testing of child occupant protection technology.

"Finding the Right FIT": Rural Patient Preferences for Fecal Immunochemical Test (FIT) Characteristics.

PURPOSE: Colorectal cancer (CRC) is the third leading cause of cancer death in the United States, yet 1 in 3 Americans have never been screened for CRC. Annual screening using fecal immunochemical tests (FITs) is often a preferred modality in populations experiencing CRC screening disparities. Although multiple studies evaluate the clinical effectiveness of FITs, few studies assess patient preferences toward kit characteristics. We conducted this community-led study to assess patient preferences for FIT characteristics and to use study findings in concert with clinical effectiveness data to inform regional FIT selection. METHODS: We collaborated with local health system leaders to identify FITs and recruit age eligible (50 to 75 years), English or Spanish speaking community members. Participants completed up to 6 FITs and associated questionnaires and were invited to participate in a follow-up focus group. We used a sequential explanatory mixed-methods design to assess participant preferences and rank FIT kits. First, we used quantitative data from user testing to measure acceptability, ease of completion, and specimen adequacy through a descriptive analysis of 1) fixed response questionnaire items on participant attitudes toward and experiences with FIT kits, and 2) a clinical assessment of adherence to directions regarding collection, packaging, and return of specimens. Second, we analyzed qualitative data from focus groups to refine FIT rankings and gain deeper insight into the pros and cons associated with each tested kit. FINDINGS: Seventy-six FITs were completed by 18 participants (Range, 3 to 6 kits per participant). Over half (56%, n = 10) of the participants were Hispanic and 50% were female (n = 9). Thirteen participants attended 1 of 3 focus groups. Participants preferred FITs that were single sample, used a probe and vial for sample collection, and had simple, large-font instructions with colorful pictures. Participants reported challenges using paper to catch samples, had difficulty labeling tests, and emphasized the importance of having care team members provide verbal instructions on test completion and follow-up support for patients with abnormal results. FIT rankings from most to least preferred were OC-Light, Hemosure iFOB Test, InSure FIT, QuickVue, OneStep+, and Hemoccult ICT. CONCLUSIONS: FIT characteristics influenced patient's perceptions of test acceptability and feasibility. Health system leaders, payers, and clinicians should select FITs that are both clinically effective and incorporate patient preferred test characteristics. Consideration of patient preferences may facilitate FIT return, especially in populations at higher risk for experiencing CRC screening disparities.

Hygiene on maternity units: lessons from a needs assessment in Bangladesh and India.

BACKGROUND: As the proportion of deliveries in health institutions increases in low- and middle-income countries, so do the challenges of maintaining standards of hygiene and preventing healthcare-associated infections (HCAIs) in mothers and babies. Adequate water, sanitation, and hygiene (WASH) and infection prevention and control (IPC) in these settings should be seen as integral parts of the broader domain of quality care. Assessment approaches are needed which capture standards for both WASH and IPC, and so inform quality improvement processes. DESIGN: A needs assessment was conducted in seven maternity units in Gujarat, India, and eight in Dhaka Division, Bangladesh in 2014. The WASH & CLEAN study developed and applied a suite of tools - a 'walkthrough checklist' which included the collection of swab samples, a facility needs assessment tool and document review, and qualitative interviews with staff and recently delivered women - to establish the state of hygiene as measured by visual cleanliness and the presence of potential pathogens, and individual and contextual determinants or drivers. RESULTS: No clear relationship was found between visually assessed cleanliness and the presence of pathogens; findings from qualitative interviews and the facility questionnaire found inadequacies in IPC training for healthcare providers and no formal training at all for ward cleaners. Lack of written policies and protocols, and poor monitoring and supervision also contributed to suboptimal IPC standards. CONCLUSIONS: Visual assessment of cleanliness and hygiene is an inadequate marker for 'safety' in terms of the presence of potential pathogens and associated risk of infection. Routine environmental screening of high-risk touch sites using simple microbiology could improve detection and control of pathogens. IPC training for both healthcare providers and ward cleaners represents an important opportunity for quality improvement. This should occur in conjunction with broader systems changes, including the establishment of functioning IPC committees, implementing standard policies and protocols, and improving health management information systems to capture information on maternal and newborn HCAIs.

Modeling Driving Performance Using In-Vehicle Speech Data From a Naturalistic Driving Study.

OBJECTIVE: We aimed to (a) describe the development and application of an automated approach for processing in-vehicle speech data from a naturalistic driving study (NDS), (b) examine the influence of child passenger presence on driving performance, and (c) model this relationship using in-vehicle speech data. BACKGROUND: Parent drivers frequently engage in child-related secondary behaviors, but the impact on driving performance is unknown. Applying automated speech-processing techniques to NDS audio data would facilitate the analysis of in-vehicle driver-child interactions and their influence on driving performance. METHOD: Speech activity detection and speaker diarization algorithms were applied to audio data from a Melbourne-based NDS involving 42 families. Multilevel models were developed to evaluate the effect of speech activity and the presence of child passengers on driving performance. RESULTS: Speech activity was significantly associated with velocity and steering angle variability. Child passenger presence alone was not associated with changes in driving performance. However, speech activity in the presence of two child passengers was associated with the most variability in driving performance. CONCLUSION: The effects of in-vehicle speech on driving performance in the presence of child passengers appear to be heterogeneous, and multiple factors may need to be considered in evaluating their impact. This goal can potentially be achieved within large-scale NDS through the automated processing of observational data, including speech. APPLICATION: Speech-processing algorithms enable new perspectives on driving performance to be gained from existing NDS data, and variables that were once labor-intensive to process can be readily utilized in future research.

American Indians' response to physical pain: functional limitations and help-seeking behaviors.

Seventy-five American Indians, ages 25 to 84, representing 14 tribal nations, participated in this study. The historical, cultural, and behavioral responses to physical pain were examined. Data were collected over a 7-month period with a survey instrument that included the Universal Pain Scale, activities of daily living, causes of pain, cultural beliefs, and self-help-seeking behaviors. Also, recommendations for Western biomedical health care professionals are offered to improve services for the American Indian population. Findings demonstrate that culture plays a crucial role in wellness and significantly affects help-seeking behaviors, treatment regimens, responses to pain, and pain management.

Challenges to recruit and retain American Indian and Alaskan Natives into social work programs: the impact on the child welfare workforce.

There is a shortage of professionally trained American Indian/Alaskan Native (AI/AN) social workers available to provide services including child welfare services to tribal communities. This study used a mixed-model survey design to examine the perceptions of 47 AI/AN BSW and MSW students enrolled in social work programs across the to determine the challenges associated with recruitment and retention. The findings are supported in the literature. Findings indicate that social work academic programs have not made substantial gains in the recruitment and retention of AI/AN students over several decades. Students identified the following seven major barriers to successful recruitment and retention: (1) a lack of AI/AN professors; (2) a shortage of field placement agencies that serve AI/AN clients; (3) conflicts between students' academic obligations and responsibilities to their families and tribal communities; (4) students' feelings of cultural isolation; (5) the need for AI/AN role models and mentors; (6) a lack of understanding by universities of cultural customs and traditional values; and (7) racism. Implications for policy and practice are offered.

American Indian grand families: a qualitative study conducted with grandmothers and grandfathers who provide sole care for their grandchildren.

A qualitative study was conducted to determine the rationale for 31 American Indian grandparents' who provide sole care of their grandchildren, the impact of historical trauma on their decision making process in accessing services, the value of American Indian Child Welfare policies in addressing care issues, and custody status of the grand families. Indian Outreach Workers, Community Health Representatives, Elder Program Directors, and tribal community leaders were key in the recruitment of participants. The grandparents were informed of the purpose of the study and participated in face-to-face, paper and pencil, individual interviews. The subjects included 29 grandmothers and two grandfathers; age 43-86 years, with 20 who lived off reservation land and 11 who lived on reservation land in Michigan. A phenomenological approach of the "world of the lived experience" informed the design of the study. The researchers recorded the subjects' responses via field notes, conducted a comparison of responses to assess internal reliability, and entered the responses into the qualitative data analysis Nvivo program. Findings included; (1) reasons for providing sole care of grandchildren (2) stressors and rewards of providing sole care (3) grandparents decisions affected by historical traumas which focused on the boarding school issues and the removal of children from their homes due to cultural differences causing a reluctance to seek and access national and state programs (4) grandparents preference was to seek and access services provided by their Tribal Nations, and/or American Indian urban agencies (5) most lacked legal custodial status which is an indicator the grandparents' may have benefited from knowledge of the Indian Child Welfare Act (ICWA).

What you count is what you target: the implications of maternal death classification for tracking progress towards reducing maternal mortality in developing countries.

The first target of the fifth United Nations Millennium Development Goal is to reduce maternal mortality by 75% between 1990 and 2015. This target is critically off track. Despite difficulties inherent in measuring maternal mortality, interventions aimed at reducing it must be monitored and evaluated to determine the most effective strategies in different contexts. In some contexts, the direct causes of maternal death, such as haemorrhage and sepsis, predominate and can be tackled effectively through providing access to skilled birth attendance and emergency obstetric care. In others, indirect causes of maternal death, such as HIV/AIDS and malaria, make a significant contribution and require alternative interventions. Methods of planning and evaluating maternal health interventions that do not differentiate between direct and indirect maternal deaths may lead to unrealistic expectations of effectiveness or mask progress in tackling specific causes. Furthermore, the need for additional or alternative interventions to tackle the causes of indirect maternal death may not be recognized if all-cause maternal death is used as the sole outcome indicator. This article illustrates the importance of differentiating between direct and indirect maternal deaths by analysing historical data from England and Wales and contemporary data from Ghana, Rwanda and South Africa. The principal aim of the paper is to highlight the need to differentiate deaths in this way when evaluating maternal mortality, particularly when judging progress towards the fifth Millennium Development Goal. It is recommended that the potential effect of maternity services failing to take indirect maternal deaths into account should be modelled.

Willingness to pay for maternal health outcomes: are women willing to pay more than men?

BACKGROUND: Only a limited number of studies have specifically sought to analyse and try to understand sex differences in willingness to pay (WTP). OBJECTIVE: To identify the role of sex in determining monetary values placed upon improvements in maternal health in Burkina Faso, West Africa. METHODS: A contingent valuation survey using the bidding game method was conducted in the district of Nouna in 2005; a sample of 409 male heads of households and their spouses were asked their WTP for a reduction in the number of maternal deaths in the Nouna area. Ordinary least squares regression analysis was employed to examine the determinants of WTP. RESULTS: Men were willing to pay significantly more than women (3127 vs 2273 West African francs), although this represented a significantly smaller proportion of their annual income (4% vs 11%). In the multivariate analyses of all respondents there was a significant positive relationship between WTP values and both starting bid and whether there had been a previous maternal complication in the respondent's household. However, there was a significant negative relationship between WTP and female sex. Once interactions between sex and income were taken into account, income did affect valuations, with a positive relationship between higher-income women and WTP values. CONCLUSION: In absolute terms, men were willing to pay more than women, while women were willing to pay a greater proportion of their income. Differences between men and women in their WTP, both in absolute terms and in terms of proportion of income, can be explained by a household effect. Future studies should distinguish between individual income and command over decision making with respect to use of individual and household income, and gain further insight into the strategies used by respondents in answering bidding game questions.

Indian Family Exception Doctrine: still losing children despite the Indian Child Welfare Act.

Since 1982, the Indian Family Exception Doctrine has been circumventing the Indian Child Welfare Act of 1978. Although not clearly defined, the doctrine has been pivotal in several American Indian child welfare cases in the United States. Over time, the doctrine continues to evolve and self-define. Several phrases have become part of the definition, such as Indian family and culture. This doctrine presents major concerns and implications in the field of child welfare.