Parental vaccine hesitancy and acceptance of a COVID-19 vaccine: An internet-based survey in the US and five Asian countries.

COVID-19 vaccination rates for children globally are relatively low. This study aimed to investigate parental vaccine hesitancy and parents' acceptance of a COVID-19 for their children for their children in the United States, China, Taiwan, India, Indonesia, and Malaysia.We analyzed data from an opt-in, internet-based cross-sectional study (n = 23,940). Parents were asked about their acceptance of a COVID-19 vaccine for their children, and if they would accept the vaccine with different risk and effectiveness profiles for themselves. Poisson regression was used to generate prevalence ratios (PR) of the relationship between vaccine acceptance for a child and vaccine profile, by country and waves and overall. Between August 2020 and June 2021, COVID-19 vaccine acceptance for children decreased in the United States (89% to 72%) and Taiwan (79% to 71%), increased in India (91% to 96%) and Malaysia (81% to 91%), and was stable in Indonesia (86%) and China (at 87%-90%). Vaccine risk and effectiveness profiles did not consistently affect parent's acceptance of a COVID-19 vaccine for their children. Instead, being not hesitant was a large driver of vaccine acceptance (PR: 1.24, 95% CI: 1.14, 1.36). Adolescent COVID-19 vaccination have already been established in many high and middle-income countries, but our study suggests that there is a movement of vaccine hesitancy which could impede the success of future pediatric and adolescent COVID-19 vaccination programs.

Hospital Finances During the First Two Years of the COVID-19 Pandemic: Evidence From Washington State Hospitals.

The COVID-19 pandemic created a broad array of challenges for hospitals. These challenges included restrictions on admissions and procedures, patient surges, rising costs of labor and supplies, and a disparate impact on already disadvantaged populations. Many of these intersecting challenges put pressure on hospitals' finances. There was concern that financial pressure would be particularly acute for hospitals serving vulnerable populations, including safety-net (SN) hospitals and critical access hospitals (CAHs). Using data from hospitals in Washington State, we examined changes in operating margins for SN hospitals, CAHs, and other acute care hospitals in 2020 and 2021. We found that the operating margins for all three categories of hospitals fell from 2019 to 2020, with SNs and CAHs sustaining the largest declines. During 2021, operating margins improved for all three hospital categories but SN operating margins still remained negative. Both changes in revenue and changes in expenses contributed to observed changes in operating margins. Our study is one of the first to describe how the financial effects of COVID-19 differed for SNs, CAHs, and other acute care hospitals over the first two years of the pandemic. Our results highlight the continuing financial vulnerability of SNs and demonstrate how the factors that contribute to profitability can shift over time.

COVID-19 vaccination preferences during a pause in Johnson & Johnson vaccine administration.

In April 2021, the US paused Janssen (J&J) COVID-19 vaccination because of reported blood clots post vaccination. This paper explores how vaccine decision-making--receiving a J&J vaccine right away vs waiting for a Pfizer vaccine--changed during the pause. In an opt-in internet-based survey April 2021 with 915 participants, 37 % were not vaccinated. Of these, 18 % would accept a J&J vaccine, 5 % would wait 1 month for a Pfizer vaccine, 25 % would wait 3 months, and 52 % would not want any vaccine. Among the unvaccinated, 56 % had heard of blood clots; 61 % of these did not want any vaccine, compared to 41 % of those who had not heard of blood clots. Moreover, among those vaccine hesitant in general, 11 % would still obtain a J&J vaccine if offered right away. These findings may suggest spillover of brand-specific adverse event concerns to the vaccine product as a whole.

Black adolescents' racial discrimination and suicide behaviors: Testing perceived school safety as a protective moderator.

The current study examined associations between Black adolescents' (Mage = 15.55, SD = 1.23) racial discrimination and suicide behaviors (i.e., suicide ideation, suicide plan, and suicide attempts), and whether perceived school safety was a protective moderator. Furthermore, we tested gender differences in relations, which were not significant. Racial discrimination predicted greater suicide behaviors, and school safety informed less suicide behaviors. School safety moderated the relation between discrimination and suicide plan, such that at low school safety, discrimination predicted having a suicide plan but was not significant at high school safety. Furthermore, school safety moderated the relation between discrimination and suicide attempts. At low school safety, discrimination predicted more suicide attempts, but was not significant at high school safety.

A Hospital-Based Infant Safe Sleep Intervention and Safe Sleep Practices Among Young Women: A Prospective Longitudinal Study.

INTRODUCTION: The rates of sudden unexpected infant death (SUID) are still high in the U.S. The longitudinal effects of SUID preventive education on infant safe sleep practices are less known. The current study evaluated the effects of a comprehensive hospital-based, SUID preventive intervention on safe infant sleep practices in the first six months of life and to identify factors associated with infant sleep practices. METHODS: Using a one-group pretest and multiple posttest design, the current quantitative study examined the impacts of the infant safe sleep intervention among 411 women recruited at a large, urban, university medical center. Participants were prospectively followed and completed four surveys from childbirth. Linear mixed models were used to evaluate the effects of the SUID prevention program on four sleep practice outcomes, including removing unsafe items from the sleeping environment, bed sharing, room sharing without bed sharing, and placing the infant in a supine sleep position. RESULTS: Compared to the baseline, participants were less likely to use unsafe items (e.g., soft bedding) in infants' sleeping areas over time. However, we found that participants reported more frequent bed sharing at 3-month and 6-month follow-ups, compared to the baseline. CONCLUSIONS: Overall, maternal education and family income were positively related to healthy infant safe sleep practices. A hospital-based preventive intervention pairing an educational initiative with home-visiting services might improve safe sleep practices to remove accidental suffocation risks from the infant sleep environment.

Adherence of those With Self-Reported Glaucoma in the United States to Eye Examination Visits.

PRCIS: The adherence of American patients with self-reported glaucoma to the follow-up recommendations is extremely low. Estimated adherence rate is lower than that obtained by previous studies that did not use a US nationally representative sample. PURPOSE: To evaluate adherence to ophthalmic outpatient follow-up visits and vision examinations in the American population aged 40 years or above. METHODS: The percentage of American patients aged≥40 years who adhered to glaucoma treatment guidelines was estimated using 2015-2019 Medical Expenditure Panel Survey (MEPS) data. Adherence was defined according to the International Council of Ophthalmology guidelines. We also compared individuals with and without self-reported glaucoma who have made at least one ophthalmic outpatient visit and at least 1 vision examination visit within a year. Differences in means and percentages were estimated to account for the covariance due to the complex sampling design. RESULTS: Approximately 4.4 million people aged or above 40 years had self-reported glaucoma in 2019 (3.21%). The rate of prevalence significantly differed with race, with Black people having the highest prevalence in all studied years. Only 7.1% (95% CI: 0.049-0.102) and 2.67% (95% CI: 0.0137-0.0519) of this population underwent at least 1 ophthalmic outpatient examination or 1 vision examination per year. Older age, never married status, higher education, eye conditions, and diabetes were significantly associated with a higher probability of ophthalmic health care use. CONCLUSIONS: Adherence to follow-up among patients with self-reported glaucoma in this population-level study was lower than that in previously reported American, non-nationally representative studies. Barriers to adherence at the population level should be assessed to inform the design of future policy or program interventions.

A study of COVID-19 vaccination in the US and Asia: The role of media, personal experiences, and risk perceptions.

The COVID-19 pandemic presents an opportunity to assess the relationship between personal experiences and vaccine decision-making. The aim of this study was to examine the associations between experiences with COVID-19 and COVID-19 vaccination status. We administered 28 repeated cross-sectional, online surveys between June 2020 and June 2021 in the US and Asia. The main exposure was media showing COVID-19 cases, and we distinguished those with no such experience, those seeing a not severe case of disease, and those seeing a severe case of disease. Logistic regression models estimated the association between experience and acceptance of a hypothetical COVID-19 vaccine (pre-rollout) or actual vaccination (post-rollout). We explored perceived susceptibility as a potential mediator. Intent to vaccinate was lowest in the US and Taiwan, and highest in India, Indonesia, and China. Across all countries, seeing a severe case of COVID-19 in the media was associated with 1.72 times higher odds of vaccination intent in 2020 (95% CI: 1.46, 2.02) and 2.13 times higher odds of vaccination in 2021 (95% CI: 1.70, 2.67), compared to those not seeing a case or a less severe case. Perceived susceptibility was estimated to mediate 25% of the relationship with hypothetical vaccination (95% CI: 18%, 31%, P<0.0001), and 16% of the relationship with actual vaccination 16% (95% CI: 12%, 19%, P<0.0001). Seriousness of experiences could relate to intention to vaccinate against COVID-19. Media exposures are a modifiable experience, and this study highlights how this experience can relate to risk perceptions and eventual vaccination, across a variety of countries where the course of the pandemic differed.

Application of Mixed Methods in Health Services Management Research: A Systematic Review.

Mixed methods research (MMR) is versatile, pragmatic, and adaptable to constraints and opportunities during a research process. Although MMR has gain popularity in health services management research, little is known about how the research approach has been used and the quality of research. We conducted a systematic review of 198 MMR articles published in selected U.S.-based and international health services management journals from 2000 through 2018 to examine the extent of MMR application and scientific rigor. Results showed limited, yet increasing, use of MMR and a high degree of correspondence between MMR designs and study purposes. However, most articles did not clearly justify using MMR designs and the reporting of method details and research integration were inadequate in a significant portion of publications. We propose a checklist to assist the preparation and review of MMR manuscripts. Additional implications and recommendations to improve transparency, rigor, and quality in MMR are discussed.

Students' perceptions of school sugar-free, food and exercise environments enhance healthy eating and physical activity.

OBJECTIVE: The objective of this study was to examine the relationships between students' perceptions of their school policies and environments (i.e. sugar-sweetened beverages (SSB) free policy, plain water drinking, vegetables and fruit eating campaign, outdoor physical activity initiative, and the SH150 programme (exercise 150 min/week at school)) and their dietary behaviours and physical activity. DESIGN: Cross-sectional study. SETTING: Primary, middle and high schools in Taiwan. PARTICIPANTS: A nationally representative sample of 2433 primary school (5th-6th grade) students, 3212 middle school students and 2829 high school students completed the online survey in 2018. RESULTS: Multivariate analysis results showed that after controlling for school level, gender and age, the students' perceptions of school sugar-free policies were negatively associated with the consumption of SSB and positively associated with consumption of plain water. Schools' campaigns promoting the eating of vegetables and fruit were positively associated with students' consumption of vegetables. In addition, schools' initiatives promoting outdoor physical activity and the SH150 programme were positively associated with students' engagement in outdoor physical activities and daily moderate-to-vigorous physical activity. CONCLUSIONS: Students' perceptions of healthy school policies and environments promote healthy eating and an increase in physical activity for students.

Effects of Parental Involvement in a Preschool-Based Eye Health Intervention Regarding Children's Screen Use in China.

In this digital era, young children spend a considerable amount of time looking at telephone, tablet, computer and television screens. However, preventative eye health behavior education could help avoid and relieve asthenopia. The effects of parental influence on their children's eye health behavior through the preschool eye health education intervention program were examined. The Health Belief Model was used to develop parental involvement strategy and eye health curriculum. The study was conducted in a large public preschool with five branches in Beijing, China. A total of 248 parent-child pairs participated in the baseline and follow-up surveys, of which 129 were in the intervention group and 119 were in the comparison group. The generalized estimating equation analysis results indicated that parental involvement in preschool-based eye health intervention on screen uses had positive influence on parents' eye health knowledge, cues to action, and parenting efficacy. The intervention program also had positive effects on the increasing level of children's eye health knowledge, beliefs, cues to action, self-efficacy, and behaviors. The results supported the implementation of a preschool-based eye health intervention program with parental involvement, which could potentially enhance children's and parents' eye health beliefs and practices.

Changes in COVID-19 risk perceptions: methods of an internet survey conducted in six countries.

OBJECTIVES: This study assessed changes in behaviors/attitudes related to the COVID-19. With the understanding that behaviors and vaccine decision-making could contribute to global spread of infectious diseases, this study collected several waves of internet-based surveys from individuals in the United States, mainland China, Taiwan, Malaysia, Indonesia, and India. The aims of this study were to (1) characterize the relationship between the epidemiology of disease and changes over time in risk perceptions, knowledge, and attitudes towards hygienic behaviors; (2) examine if risk perceptions affect acceptance of less-than-ideal vaccines; and (3) contrast adherence to public health recommendations across countries which have had different governmental responses to the outbreak. DATA DESCRIPTION: We conducted cross-sectional online surveys in six countries from March 2020 to April 2021. By the end of June 2021, there will be six waves of surveys for the United States and China, and four waves for the rest of countries. There are common sets of questions for all countries, however, some questions were adapted to reflect local situations and some questions were designed intentionally for specific countries to capture different COVID-19 mitigation actions. Participants were asked about their adherence towards countermeasures, risk perceptions, and acceptance of a hypothetical vaccine for COVID-19.

Differential Effect of Vaccine Effectiveness and Safety on COVID-19 Vaccine Acceptance across Socioeconomic Groups in an International Sample.

Controlling the spread of SARS-CoV-2 will require high vaccination coverage, but acceptance of the vaccine could be impacted by perceptions of vaccine safety and effectiveness. The aim of this study was to characterize how vaccine safety and effectiveness impact acceptance of a vaccine, and whether this impact varied over time or across socioeconomic and demographic groups. Repeated cross-sectional surveys of an opt-in internet sample were conducted in 2020 in the US, mainland China, Taiwan, Malaysia, Indonesia, and India. Individuals were randomized into receiving information about a hypothetical COVID-19 vaccine with different safety and effectiveness profiles (risk of fever 5% vs. 20% and vaccine effectiveness 50% vs. 95%). We examined the effect of the vaccine profile on vaccine acceptance in a logistic regression model, and included interaction terms between vaccine profile and socioeconomic/demographic variables to examine the differences in sensitivity to the vaccine profile. In total, 12,915 participants were enrolled in the six-country study, including the US (4054), China (2797), Taiwan (1278), Malaysia (1497), Indonesia (1527), and India (1762). Across time and countries, respondents had stronger preferences for a safer and more effective vaccine. For example, in the US in November 2020, acceptance was 3.10 times higher for a 95% effective vaccine with a 5% risk of fever, vs a vaccine 50% effective, with a 20% risk of fever (95% CI: 2.07, 4.63). Across all countries, there was an increase in the effect of the vaccine profile over time (p < 0.0001), with stronger preferences for a more effective and safer vaccine in November 2020 compared to August 2020. Sensitivity to the vaccine profile was also stronger in August compared to November 2020, in younger age groups, among those with lower income; and in those that are vaccine hesitant. Uptake of COVID-19 vaccines could vary in a country based upon effectiveness and availability. Effective communication tools will need to be developed for certain sensitive groups, including young adults, those with lower income, and those more vaccine hesitant.

Vaccine Hesitancy and Rejection of a Vaccine for the Novel Coronavirus in the United States.

The arrival of the COVID-19 vaccine has been accompanied by increased discussion of vaccine hesitancy. However, it is unclear if there are shared patterns between general vaccine hesitancy and COVID-19 vaccine rejection, or if these are two different concepts. This study characterized rejection of a hypothetical COVID-19 vaccine, and compared patterns of association between general vaccine hesitancy and COVID-19 vaccine rejection. The survey was conducted online March 20-22, 2020. Participants answered questions on vaccine hesitancy and responded if they would accept the vaccine given different safety and effectiveness profiles. We assessed differences in COVID-19 rejection and general vaccine hesitancy through logistic regressions. Among 713 participants, 33.0% were vaccine hesitant, and 18.4% would reject a COVID-19 vaccine. Acceptance varied by effectiveness profile: 10.2% would reject a 95% effective COVID-19 vaccine, but 32.4% would reject a 50% effective vaccine. Those vaccine hesitant were significantly more likely to reject COVID-19 vaccination [odds ratio (OR): 5.56, 95% confidence interval (CI): 3.39, 9.11]. In multivariable logistic regression models, there were similar patterns for vaccine hesitancy and COVID-19 vaccine rejection by gender, race/ethnicity, family income, and political affiliation. But the direction of association flipped by urbanicity (P=0.0146, with rural dwellers less likely to be COVID-19 vaccine rejecters but more likely to be vaccine hesitant in general), and age (P=0.0037, with fewer pronounced differences across age for COVID-19 vaccine rejection, but a gradient of stronger vaccine hesitancy in general among younger ages). During the COVID-19 epidemic's early phase, patterns of vaccine hesitancy and COVID-19 vaccine rejection were relatively similar. A significant minority would reject a COVID-19 vaccine, especially one with less-than-ideal effectiveness. Preparations for introducing the COVID-19 vaccine should anticipate substantial hesitation and target concerns, especially among younger adults.

Prenatal Phthalates Exposure and Cord Thyroid Hormones: A Birth Cohort Study in Southern Taiwan.

BACKGROUND: The regulation of thyroid hormones in the early stages of gestation plays a crucial role in the outcome of a pregnancy. Furthermore, thyroid hormones are fundamental for the fetal development of all organs, including endocrine hormone changes in uterus. Endocrine disrupting chemicals have been shown to have an effect on thyroid hormone homeostasis in newborns, which affects their later development. Few studies have proposed how phthalates could alter thyroid function through several mechanisms and the possible effects on thyroid hormone homeostasis of phthalates on pregnant women. However, the effects of cord blood phthalates and prenatal phthalate exposure on thyroid hormones in newborns remain unclear. OBJECTIVES: We aim to follow up on our previous established subjects and determine the correlation between phthalate exposure and thyroid hormones in pregnant women and newborns. MATERIALS AND METHODS: We recruited 61 pregnant women from the Obstetrics and Gynecology Department of a medical hospital in southern Taiwan and followed up. High performance liquid chromatography electrospray ionization tandem mass spectrometry (HPLC-ESI-MS/MS) was used to analyze urine samples for five phthalate metabolites. Serum levels of thyroid hormones were analyzed using electrochemoluminescence immunoassay (ECLIA) method. We used Spearman and Pearson correlation coefficients to evaluate the correlation between each phthalate metabolites in serum and the thyroid hormone levels in fetus and parturient. Finally, multiple logistic regression was used to explore the relationship between hormones and their corresponding phthalate metabolites in cord blood. RESULTS: High MBP in cord blood was correlated with negative cord serum TSH in newborns (r = -0.25, p < 0.06). By using multiple linear regression after adjusting for potential confounders (gestational and maternal age), cord serum MBP levels showed a negative association with cord serum TSH (ß = 0.217, p < 0.05), cord serum T4 (ß = 1.71, p < 0.05) and cord serum T4 × TSH (ß = 42.8, p < 0.05), respectively. CONCLUSION: We found that levels of cord serum TSH and T4 in newborns was significantly negatively associated with cord serum MBP levels after adjusting for significant covariate. The fall in TSH in newborns may potentially be delaying their development.

Modification of a vaccine hesitancy scale for use in adult vaccinations in the United States and China.

Most research on vaccine hesitancy has focused on parental attitudes toward childhood vaccination, but it will be important to understand dimensions of vaccine hesitancy in the adult population as more adult vaccines are introduced in the future. We modified the Vaccine Hesitancy Scale to target adult vaccines and provide measures of its reliability and validity relative to influenza vaccine uptake and COVID-19 vaccination acceptance in cross-sectional internet surveys in the United States and in China. We assessed the impact of vaccine hesitancy on influenza and COVID-19 vaccination using multivariable regression modeling, which informed concurrent validity of the adult Vaccine Hesitancy Scale (aVHS). Among 1103 participants in the March 2020 China survey, 5.4% would not accept a COVID-19 vaccine, whereas this figure was 18.8% for the March 2020 US survey and 27.3% for the June 2020 US survey. The aVHS exhibits good internal consistency in all three surveys. Models adjusted for age, gender and income level show that prevalence of COVID-19 vaccine acceptance was a fraction as high in those who scored higher on the VHS than those who scored lower on all three surveys. Prevalence of past and future flu vaccine acceptance was a fraction as high in those with higher aVHS scores than those with lower scores. Prevalence of COVID-19 vaccine acceptance is lower in those with higher vaccine hesitancy scores, which supports the scale's concurrent validity. The aVHS exhibits good internal consistency, making it a valid and reliable tool for measuring vaccination uptake.

Mediation effects of thyroid function in the associations between phthalate exposure and glucose metabolism in adults.

The mediating influence of thyroid function on the association of phthalate exposure with glucose metabolism, including insulin resistance, remains unclear. We explored the mediating influence of thyroid hormone levels on the phthalate exposure-insulin resistance association. This cross-sectional study of 217 Taiwanese adults assessed insulin resistance (Homeostatic Model Assessment for Insulin Resistance, HOMA-IR scores) and the levels of 11 urinary phthalate metabolites and 5 thyroid hormones. Multiple regression models were used to analyze the associations among serum thyroid hormone levels, urinary phthalate metabolite levels, and HOMA-IR scores. The mediation analysis assessed the influence of thyroid function on the phthalate exposure-HOMA-IR association. Our data indicated urinary mono-ethylhexyl phthalate (MEHP) levels was negatively associated with free thyroxine (T4) (ß = -0.018; 95% confidence interval [CI]: -0.031, -0.005) and positively associated with HOMA-IR scores (ß = 0.051, 95% CI: 0.012, 0.090). The study also revealed urinary mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP) levels was negatively associated with free T4 (ß = -0.036, 95% CI: -0.056, -0.017) and HOMA-IR (ß = 0.070, 95% CI: 0.013, 0.126). Free T4 and HOMA-IR had a negative association (ß = -0.757, 95% CI: -1.122, -0.392). In the mediation analysis, free T4 mediated 24% and 35% of the associations of urinary MEHP and MEOHP with HOMA-IR, respectively. Our findings revealed the mediating role of thyroid function in the phthalate exposure-glucose metabolism association in adults.

Social distancing in response to the novel coronavirus (COVID-19) in the United States.

In order to reduce the spread of SARS-CoV-2, much of the US was placed under social distancing guidelines during March 2020. We characterized risk perceptions and adherence to social distancing recommendations in March 2020 among US adults aged 18+ in an online survey with age and gender quotas to match the general US population (N = 713). We used multivariable logistic and linear regression to estimate associations between age (by generational cohort) and these outcomes. The median perceived risk of infection with COVID-19 within the next month was 32%, and 65% of individuals were practicing more social distancing than before the outbreak. Baby Boomers had lower perceived risk than Millennials (-10.6%, 95% CI: -16.2%, -5.0%), yet were more frequently social distancing (OR = 1.64; 95% CI: 1.05, 2.56). Public health outreach should focus on raising compliance with social distancing recommendations, especially among high risk groups. Efforts to address risk perceptions alone may be inadequate.

Urinary phthalate metabolites are associated with biomarkers of DNA damage and lipid peroxidation in pregnant women - Tainan Birth Cohort Study (TBCS).

Phthalate exposure and oxidative stress have been linked to adverse reproductive outcomes in experimental studies, whereas no clear line has been drawn for human, especially in pregnant women. This study explored relationships between urinary phthalate metabolites and biomarkers of lipid peroxidation and oxidative and nitrosative DNA damage. Measurements from 97 Taiwanese pregnant women were taken at three different times during second and third trimesters. Five oxidative/nitrosative stress biomarkers - 8-hydroxy-2'-deoxyguanosine (8-OHdG), 8-nitroguanine (8-NO2Gua), 4-hydroxy-2-nonenal-mercapturic acid (HNE-MA), 8-isoprostaglandin F2α (8-isoPF2α), and malondialdehyde (MDA), and 11 phthalate metabolites were measured in urine samples. Linear regressions in each visit and linear mixed-model regressions were fitted to estimate percent changes in oxidative/nitrosative stress biomarkers resulting from inter-tertile increase of phthalate metabolite level and the cumulative concentrations of di (2-ethylhexyl) phthalate (DEHP) and dibutyl phthalate. The highest urine concentrations of phthalate metabolites and the greatest number of significant positive associations between phthalate metabolites and oxidative/nitrosative stress biomarkers were observed in the third visit and in repeated measurements analysis, respectively. Of the biomarkers related to DNA damage, 8-OHdG (25.4% inter-tertile increase for mono-iso-butyl phthalate) was more sensitive to phthalate exposure than 8-NO2Gua. Among the biomarkers of lipid peroxidation, HNE-MA (61.2% inter-tertile increase for sum of DEHP metabolites) was more sensitive than 8-isoPF2α and MDA. Our findings support the hypothesis that pregnant phthalate exposure increases the oxidative stress biomarkers of DNA damage and lipid peroxidation. Future research may elucidate the mediating roles of oxidative/nitrosative stress biomarkers in the link between phthalate exposure and adverse reproductive outcomes.

Pregnant women's attitudes and decision-making regarding prenatal Down syndrome screening and diagnosis: scale development and validation.

BACKGROUND: Down syndrome is a common chromosomal abnormality and prenatal screening can inform parents of the risk of their baby having Down syndrome. Little research has examined how decisions regarding both Down syndrome screening as well as diagnosis are made among women who are currently pregnant and how their decisions are influenced by their social contexts, specifically family and social media, using mixed methods. The study was to test the validity and reliability of a scale that measures pregnant women's attitudes and decision-making concerning prenatal Down syndrome screening and diagnosis in urban areas of Taiwan. METHODS: We developed an item pool based on a literature review and in-depth interviews with 30 pregnant women recruited at two district hospitals in urban areas. The item pool was reviewed by a panel of experts and then administered to 300 women who had been pregnant for less than 24 weeks and had not received the Down syndrome screening tests. We used item analysis and exploratory factor analysis to validate the scale and test its reliability. RESULTS: The initial item pool had 54 items. After the expert review, three items were deleted. After the item analysis, 16 additional items were deleted. Exploratory factor analysis of the remaining items revealed four factors labeled - "Attitudes towards Down syndrome and Screening Tests," "Important others' Attitudes towards Down Syndrome," "Influence of Important Others on Decision-Making," and "Influence of Social Media on Decision-Making" - and 16 of the remaining items had satisfactory loadings on those factors, explaining 72.0% of the total variance. The Cronbach's α values of the dimensions ranged between 0.75 and 0.90, demonstrating satisfactory internal reliability. CONCLUSIONS: The scale has satisfactory validity and reliability, and can be used to understand pregnant women's attitudes and decision-making regarding Down syndrome screening and diagnosis, and to help design tailored consultations for pregnant women in clinical settings.

Characterization of phthalate exposure in relation to serum thyroid and growth hormones, and estimated daily intake levels in children exposed to phthalate-tainted products: A longitudinal cohort study.

BACKGROUND: No information is available on the long-term effects on thyroid and growth hormones of children exposed to phthalate-tainted products, despite the infamous 2011 Taiwan phthalate episode. We investigated estimated daily intake levels and their long-term effects on serum thyroid and growth hormone levels in children. METHODS: We recruited 166 children (2-18 years old) in three visits who provided specimens and filled out a questionnaire from the Risk Assessment of Phthalate Incident in Taiwan (RAPIT) project study from 2012 to 2016. Morning spot urine samples were analyzed for nine phthalate metabolites. Serum thyroid (triiodothyronine [T3], thyroxine [T4], and free T4) and growth hormone (insulin-like growth factor-1 [IGF-1] and its binding protein 3 [IGF-BP3]) levels were measured. A generalized estimating equation model was used to evaluate associations between phthalate metabolite levels and children's thyroid and growth hormone levels. RESULTS: The median metabolite levels of monomethyl phthalate (MMP), Σdibutyl phthalate (DBP), and Σdi-(2-ethylhexyl) phthalate (DEHP) at visits 1, 2, and 3 were 6.59, 10.5, and 21.0 ng/mL, 0.15, 0.24, and 0.20 nmol/mL, and 0.15, 0.17, and 0.12 nmol/mL, respectively. After adjusting for potential confounding factors, we found that levels of urinary MMP were negatively associated with T3 (ß = -0.013, p = 0.047), T4 (ß = -0.016, p = 0.006), free T4 (ß = -0.012, p = 0.002), and IGF-BP3 (ß = -0.025, p = 0.003). Urinary mono-ethyl phthalate (MEP) was negatively associated with IGF-1 (ß = -0.027, p = 0.029) and IGF-BP3 (ß = -0.016, p = 0.018). In addition, serum free T4 was positively associated with urinary mono-2-ethyl-5-hydroxy hexyl phthalate (MEHHP) (ß = 0.016, p = 0.043), mono-2-ethyl-5-oxohexyl phthalate (MEOHP) (ß = 0.015, p = 0.024), and ΣDEHPm (ß = 0.019, p = 0.020). CONCLUSIONS: Our findings support the hypothesis that specific phthalates disturb the hemostasis of thyroid and growth hormone levels in children exposed to phthalate-tainted products.