Quality Improvement Increases Pediatric Community Hospital Smoking Cessation Interventions.

BACKGROUND: Tobacco use commonly starts during adolescence and is the leading cause of preventable disease, disability, and death in the United States. Secondhand smoke (SHS) exposure increases asthma and respiratory infection hospitalizations and contributes to sudden unexpected infant death. Few pediatric hospitalist-led smoking cessation studies are formal quality improvement (QI), with most at academic institutions and studying caregivers. OBJECTIVES: To increase SHS exposure/tobacco use screening, smoking cessation discharge instructions, and Smokers' Helpline referrals for community hospital pediatric patients/caregivers through QI. METHODS: All pediatric, newborn, and NICU admissions were eligible. The baseline period was December 2019 through November 2020 and intervention period December 2020 through June 2021. Interventions included hospitalist education, standardizing documentation, visual reminders, and Helpline wallet cards. The primary measure was monthly percentage of patients screened for SHS exposure/tobacco use. Secondary measures were percentage of patients/caregivers positive for SHS exposure/tobacco use who received (1) discharge instructions or (2) Helpline referral. Length of stay was a balancing measure. Primary and balancing measures were analyzed with statistical process control. Secondary measures were monitored on run charts. RESULTS: Average SHS exposure/tobacco use screening rates increased from 14% to 90%, meeting special cause variation beginning December 2020. Median discharge instructions increased from 0% to 56%. Helpline referrals increased from 0% to 17%. Length of stay remained approximately 2 days. CONCLUSIONS: Pediatrician-led QI can increase SHS exposure/tobacco use screening and interventions in the community hospital setting to encourage smoke exposure reduction and smoking cessation for patients and caregivers.

Exposure and Use of Mobile Media Devices by Young Children.

BACKGROUND AND OBJECTIVES: Research on children's use of mobile media devices lags behind its adoption. The objective of this study was to examine young children's exposure to and use of mobile media devices. METHODS: Cross-sectional study of 350 children aged 6 months to 4 years seen October to November 2014 at a pediatric clinic in an urban, low-income, minority community. The survey was adapted from Common Sense Media's 2013 nationwide survey. RESULTS: Most households had television (97%), tablets (83%), and smartphones (77%). At age 4, half the children had their own television and three-fourths their own mobile device. Almost all children (96.6%) used mobile devices, and most started using before age 1. Parents gave children devices when doing house chores (70%), to keep them calm (65%), and at bedtime (29%). At age 2, most children used a device daily and spent comparable screen time on television and mobile devices. Most 3- and 4-year-olds used devices without help, and one-third engaged in media multitasking. Content delivery applications such as YouTube and Netflix were popular. Child ownership of device, age at first use, and daily use were not associated with ethnicity or parent education. CONCLUSIONS: Young children in an urban, low-income, minority community had almost universal exposure to mobile devices, and most had their own device by age 4. The patterns of use suggest early adoption, frequent and independent use, and media multitasking. Studies are urgently needed to update recommendations for families and providers on the use of mobile media by young children.

Ebola infection control in Sierra Leonean health clinics: A large cross-agency cooperative project.

The Ebola virus disease outbreak occurring in West Africa has resulted in at least 199 cases of Ebola in Sierra Leonean health care workers, many as a result of transmission occurring in health facilities. The Ministry of Health and Sanitation of Sierra Leone recognized that improvements in infection prevention and control (IPC) were necessary at all levels of health care delivery. To this end, the U.S. Centers for Disease Control and Prevention, United Nations Children's Fund, and multiple nongovernmental organizations implemented a national IPC training program in 1,200 peripheral health units (PHUs) in Sierra Leone. A tiered training of trainers program was used. Trainers conducted multiday trainings at PHUs and coordinated the delivery of personal protective equipment (gloves, gowns, masks, boots) and infection control supplies (chlorine, buckets, disposable rags, etc) to all PHU staff. Under the ongoing project, 4,264 health workers have already been trained, and 98% of PHUs have received their first shipment of supplies.

Can health workers reliably assess their own work? A test-retest study of bias among data collectors conducting a Lot Quality Assurance Sampling survey in Uganda.

BACKGROUND: Lot Quality Assurance Sampling (LQAS) is a classification method that enables local health staff to assess health programmes for which they are responsible. While LQAS has been favourably reviewed by the World Bank and World Health Organization (WHO), questions remain about whether using local health staff as data collectors can lead to biased data. METHODS: In this test-retest research, Pallisa Health District in Uganda is subdivided into four administrative units called supervision areas (SA). Data collectors from each SA conducted an LQAS survey. A week later, the data collectors were swapped to a different SA, outside their area of responsibility, to repeat the LQAS survey with the same respondents. The two data sets were analysed for agreement using Cohens' kappa coefficient and disagreements were analysed. RESULTS: Kappa values ranged from 0.19 to 0.97. On average, there was a moderate degree of agreement for knowledge indicators and a substantial level for practice indicators. Respondents were found to be systematically more knowledgeable on retest indicating bias favouring the retest, although no evidence of bias was found for practices indicators. CONCLUSIONS: In this initial study, using local health care providers to collect data did not bias data collection. The bias observed in the knowledge indicators is most likely due to the 'practice effect', whereby respondents increased their knowledge as a result of completing the first survey, as no corresponding effect was seen in the practices indicators.

Improving malaria treatment and prevention in India by aiding district managers to manage their programmes with local information: a trial assessing the impact of Lot Quality Assurance Sampling on programme outcomes.

OBJECTIVES: This paper reports the first trial of Lot Quality Assurance Sampling (LQAS) assessing associations between access to LQAS data and subsequent improvements in district programming. This trial concerns India's approach to addressing an increase in malaria-attributable deaths by training community health workers to diagnose, treat and prevent malaria, while using LQAS to monitor sub-district performance and make programme improvements. METHODS: The Ministry of Health introduced LQAS into four matched high malaria burden districts (Annual Parasite Incidence >5) (N > 5 million). In each sub-district, we sampled four populations in three 6-monthly surveys: households, children <5 years, people with fever in the last 2 weeks and community health workers. In three districts, trained local staff collected, analysed and used data for programme management; in one control district, non-local staff collected data and did not disseminate results. For eight indicators, we calculated the change in proportion from survey one to three and used a Difference-in-Differences test to compare the relative change between intervention and control districts. RESULTS: Coverage increased from survey one to three for 24 of 32 comparisons. Difference-in-Differences tests revealed that intervention districts exhibited significantly greater change in four of six vertical strategies (insecticide treated bed-nets and indoor residual spraying), one of six treatment-seeking behaviours and four of 12 health worker capacity indicators. The control district displayed greater improvement than two intervention districts for one health worker capacity indicator. One district with poor management did not improve. CONCLUSIONS: In this study, LQAS results appeared to support district managers to increase coverage in underperforming areas, especially for vertical strategies in the presence of diligent managers.

Putting the C back into the ABCs: a multi-year, multi-region investigation of condom use by Ugandan youths 2003-2010.

A major strategy for preventing transmission of HIV and other STIs is the consistent use of condoms during sexual intercourse. Condom use among youths is particularly important to reduce the number of new cases and the national prevalence. Condom use has been often promoted by the Uganda National AIDS Commission. Although a number of studies have established an association between condom use at one's sexual debut and future condom use, few studies have explored this association over time, and whether the results are generalizable across multiple locations. This multi time point, multi district study assesses the relationship between sexual debut and condom use and consistent use of condoms thereafter. Uganda has used Lot Quality Assurance Sampling surveys since 2003 to monitor district level HIV programs and improve access to HIV health services. This study includes 4518 sexually active youths interviewed at five time points (2003-2010) in up to 23 districts located across Uganda. Using logistic regression, we measured the association of condom use at first sexual intercourse on recent condom usage, controlling for several factors including: age, sex, education, marital status, age at first intercourse, geographical location, and survey year. The odds of condom use at last intercourse, using a condom at last intercourse with a non-regular partner, and consistently using a condom are, respectively, 9.63 (95%WaldCI = 8.03-11.56), 3.48 (95%WaldCI = 2.27-5.33), and 11.12 (95%WaldCI = 8.95-13.81) times more likely for those individuals using condoms during their sexual debut. These values did not decrease by more than 20% when controlling for potential confounders. The results suggest that HIV prevention programs should encourage condom use among youth during sexual debut. Success with this outcome may have a lasting influence on preventing HIV and other STIs later in life.

Improving the collection of knowledge, attitude and practice data with community surveys: a comparison of two second-stage sampling methods.

BACKGROUND: Second-stage sampling techniques, including spatial segmentation, are widely used in community health surveys when reliable household sampling frames are not available. In India, an unresearched technique for household selection is used in eight states, which samples the house with the last marriage or birth as the starting point. Users question whether this last-birth or last-marriage (LBLM) approach introduces bias affecting survey results. METHODS: We conducted two simultaneous population-based surveys. One used segmentation sampling; the other used LBLM. LBLM sampling required modification before assessment was possible and a more systematic approach was tested using last birth only. We compared coverage proportions produced by the two independent samples for six malaria indicators and demographic variables (education, wealth and caste). We then measured the level of agreement between the caste of the selected participant and the caste of the health worker making the selection. RESULTS: No significant difference between methods was found for the point estimates of six malaria indicators, education, caste or wealth of the survey participants (range of P: 0.06 to >0.99). A poor level of agreement occurred between the caste of the health worker used in household selection and the caste of the final participant, (Κ = 0.185), revealing little association between the two, and thereby indicating that caste was not a source of bias. CONCLUSIONS: Although LBLM was not testable, a systematic last-birth approach was tested. If documented concerns of last-birth sampling are addressed, this new method could offer an acceptable alternative to segmentation in India. However, inter-state caste variation could affect this result. Therefore, additional assessment of last birth is required before wider implementation is recommended.