Beyond Sociodemographic and COVID-19-Related Factors: The Association Between the Need for Psychological and Information Support from School and Anxiety and Depression.

BACKGROUND In addition to sociodemographic and COVID-19- related factors, the needs of school support, including material, psychological and information support, have seldom been discussed as factors influencing anxiety and depression among college students during the COVID-19 pandemic. MATERIAL AND METHODS In this cross-sectional study, 3351 college students from China were surveyed through questionnaires about their sociodemographic and COVID-19 characteristics, the needs of school support, and their experiences with anxiety and depression. RESULTS Anxiety and depression were reported by 6.88% and 10.50% of students, respectively. Married, higher education, non-medical, and urban students had significantly higher risks of anxiety or depression. Additionally, symptoms such as cough and fever, especially when following a possible contact with suspected individuals, quarantine history of a personal contact, going out 1-3 times a week, not wearing a mask, and spending 2-3 hours browsing COVID-19-related information were significantly associated with the occurrence of anxiety or depression. Those who used methods to regulate their emotional state, used a psychological hotline, and who had visited a psychiatrist showed higher anxiety or depression. Those who used online curricula and books, used preventive methods for COVID-19, and who had real-time information about the epidemic situation of the school showed lower anxiety and depression. CONCLUSIONS In addition to sociodemographic and COVID-19-related aspects, students' needs for psychological assistance and information from schools were also associated with anxiety and depression among college students.

State Wellness Policy Requirement Laws Matter for District Wellness Policy Comprehensiveness and Wellness Policy Implementation in the United States.

Beginning with the school year 2006-2007, U.S. school districts participating in the federal Child Nutrition Programs were required to adopt and implement a local wellness policy (LWP) that included goals and/or standards for nutrition education, school meals, other foods sold or served in schools, and physical activity. A primary challenge with LWPs has been inconsistent implementation. This study examined whether state wellness policy requirement laws and district LWP comprehensiveness influence district level implementation, using law/policy data from the National Wellness Policy Study and school food authority (SFA)-reported district LWP implementation from the School Nutrition and Meal Cost Study. Generalized linear and structural equation models were used, controlling for SFA and district characteristics. SFAs in states with wellness policy requirement laws (vs. those in states without) reported implementing significantly more practices (59.56% vs. 44.57%, p < 0.01). State wellness policy requirement laws were associated with district LWP comprehensiveness (coeff.: 0.463; 95% CI: 0.123, 0.803) and district-level implementation (coeff.: 1.392; 95% CI: 0.299, 2.485). District LWP comprehensiveness was associated with district implementation (coeff.: 0.562; 95% CI: 0.072, 1.053), but did not mediate the state law-district implementation relationship. This study highlights the important role that state laws and district LWPs can play in facilitating wellness policy implementation.

Healthcare and education networks interaction as an indicator of social services stability following natural disasters.

Healthcare and education systems have been identified by various national and international organizations as the main pillars of communities' stability. Understanding the correlation between these main social services institutions is critical to determining the tipping point of communities following natural disasters. Despite being defined as social services stability indicators, to date, no studies have been conducted to determine the level of interdependence between schools and hospitals and their collective influence on their recoveries following extreme events. In this study, we devise an agent-based model to investigate the complex interaction between healthcare and education networks and their overall recovery, while considering other physical, social, and economic factors. We employ comprehensive models to simulate the functional processes within each facility and to optimize their recovery trajectories after earthquake occurrence. The results highlight significant interdependencies between hospitals and schools, including direct and indirect relationships, suggesting the need for collective coupling of their recovery to achieve full functionality of either of the two systems following natural disasters. Recognizing this high level of interdependence, we then establish a social services stability index, which can be used by policymakers and community leaders to quantify the impact of healthcare and education services on community resilience and social services stability.

Wellness School Assessment Tool Version 3.0: An Updated Quantitative Measure of Written School Wellness Policies.

Schools play an important role in promoting student wellness. As directed by the Healthy Hunger-Free Kids Act, the US Department of Agriculture updated the requirements for written school wellness policies in 2016. The WellSAT (Wellness School Assessment Tool) is an online tool that provides a quantitative score for wellness policy comprehensiveness and strength. The WellSAT has been updated 3 times over the past decade to remain current with federal law and best practices. In this article, we describe the process of updating to WellSAT 3.0. The steps included: reviewing the language of each item linked to a federal provision; adding and deleting items based on frequencies from the National Wellness Policy Study and the empirical support for specific policies; gathering feedback from a survey of experts (N = 77) about best practices and measure usability; and establishing intercoder reliability in a national sample (N = 50) of policies. We conclude with recommendations and guidance for the use of WellSAT 3.0.

Aspects of protection and social vulnerability of teenagers in public all-day schools.

OBJECTIVE: identify and analyze aspects related to social vulnerability of a group of teenagers of a public all-day school with regard to harmful and abusive use of psychoactive drugs. METHODS: a strategic social study, with a qualitative approach, was carried out with 49 teenagers of a public all-day secondary school. Focus groups were carried out between 2016 and 2017, and the resulting material was transcribed and analyzed by means of thematic content analysis, resulting in the following categories: The family I come from; Birds of a feather; If I'm studying, how can I work?; Drugs: a non-parallel universe. RESULTS: social vulnerability was associated with unequal income distribution, fragile social relations affected by the harmful use of drugs and vulnerability of public all-day schools. Final considerations: all-day schools did not appear as an effective tool to break away with the context of social vulnerability regarding the use of drugs.

Prevalence and socio-demographic correlates of accelerometer measured physical activity levels of school-going children in Kampala city, Uganda.

BACKGROUND: The current international physical activity guidelines for health recommend children to engage in at least 60 minutes of moderate-to-vigorous physical activity (MVPA) daily. Yet, accurate prevalence estimates of physical activity levels of children are unavailable in many African countries due to the dearth of accelerometer-measured physical activity data. The aim of this study was to describe the prevalence and examine the socio-demographic correlates of accelerometer-measured physical activity among school-going children in Kampala city, Uganda. METHODS: A cross-sectional study design was used to recruit a sample of 10-12 years old school-going children (n = 256) from 7 primary schools (3 public schools and 4 private schools) in Kampala city, Uganda. Sedentary time, light-intensity physical activity (LPA), moderate-intensity physical activity (MPA) and vigorous-intensity physical activity (VPA) were measured by accelerometers (ActiGraph GT3X+ [Pensacola, Florida, USA]) over a seven-day period. Socio-demographic factors were assessed by a parent/guardian questionnaire. Weight status was generated from objectively measured height and weight and computed as body mass index (BMI). Multi-level logistic regressions identified socio-demographic factors that were associated with meeting physical activity guidelines. RESULTS: Children's sedentary time was 9.8±2.1 hours/day and MVPA was 56±25.7 minutes/day. Only 36.3% of the children (38.9% boys, 34.3% girls) met the physical activity guidelines. Boys, thin/normal weight and public school children had significantly higher mean daily MVPA levels. Socio-demographic factors associated with odds of meeting physical activity guidelines were younger age (OR = 0.68; 95% CI = 0.55-0.84), thin/normal weight status (OR = 4.08; 95% CI = 1.42-11.76), and socioeconomic status (SES) indicators such as lower maternal level of education (OR = 2.43; 95% CI = 1.84-3.21) and no family car (OR = 0.31; 95% CI = 0.17-0.55). CONCLUSION: Children spent a substantial amount of time sedentary and in LPA and less time in MVPA. Few children met the physical activity guidelines. Lower weight status, lower maternal education level and no family car were associated with meeting physical activity guidelines. Effective interventions and policies to increase physical activity among school-going children in Kampala, are urgently needed.

Putting Policy Into Practice: School-Level Compliance With and Implementation of State Concussion Laws.

CONTEXT: Each year, approximately 2 million US children 18 years or younger sustain a concussion, a type of mild traumatic brain injury (TBI). Concussions can have detrimental effects on physical, cognitive, emotional, or sleep health. POLICY: Between 2009 and 2014, all 50 US states and Washington, District of Columbia, enacted state concussion laws aimed to increase awareness about concussion and reduce the prevalence and severity of this injury. Most state laws include the following core tenets: (1) immediate removal from play after an actual or suspected concussion; (2) medical clearance before an athlete can return to play (RTP); and (3) concussion education for athletes, parents, and coaches. IMPLEMENTATION: State concussion laws allow for substantial interpretation at the school level, resulting in considerable variation in the content of school written concussion policies and the level of implementation of state law requirements at the school level. EVALUATION: We assessed the degree of high school written concussion policy compliance with the respective state law and examined the relationship between concussion policy compliance and school-level implementation of concussion laws. Seventy-one school officials completed a semistructured telephone interview and submitted their school's written concussion policy. Of the 71 policies analyzed, most complied with the removal-from-play, RTP, and concussion education tenets (90.1%, 97.2%, and 76.1%, respectively). The majority of participants reported that their school implemented the removal-from-play (91.5%), RTP (93.0%), and concussion education (80.6%) tenets well or very well. No significant relationships were found between researcher-rated school policy compliance and school-reported implementation of state law requirements at the school level. DISCUSSION: Our findings suggest that most participating schools complied with their state concussion law and implemented law requirements well or very well. Future studies should identify facilitators and barriers to the implementation of state concussion laws at the school level.

Predicting economics student retention in higher education: The effects of students' economic competencies at the end of upper secondary school on their intention to leave their studies in economics.

Despite the importance of acquiring economic competencies at the secondary level and the worldwide popularity of economics in higher education, there is almost no research on the effects of economic competencies on economics student retention. Based on a longitudinal sample of 538 high school students in Switzerland, this study provides the first results on this topic. The longitudinal study took place from 2011 to 2016 and comprised two points of measurement. Economic competencies were measured multidimensionally and comprised knowledge and skills, as well as attitude, value-oriented dispositions, interest and motivation. Different student retention models were adapted and combined to explain student retention in the field of economics. According to these models, students' academic and social integration are key mediators to predict their retention. Based on these theoretical explanations, structural equation modelling was then used to test the long-term effects of high school students' economic competencies at the end of upper-secondary school on their retention in studying in the field of economics. The results show that economic competencies predict economics students' academic integration (as measured by grade point average) but not their social integration. Additionally, the data confirm that academic and social integration are strong mediators for their retention. In addition to economic competencies, students' cognitive abilities, prior schooling (school grades, school profile, and school type) and perceived family support predict student retention in economics. Overall, economic competencies account for a substantial proportion of the variance in student retention. Against this background, the results indicate that fostering high school students' economic competencies plays a crucial role in their study success in the field of economics.

Preschool Quality Effects on Learning Behavior and Later Achievement in Germany: Moderation by Socioeconomic Status.

This study investigates whether children's preschool experiences are associated with later achievement via enhanced learning behaviors using data from a German longitudinal study following children (N = 554) from age 3 in preschool to age 8 in second grade. There were two main findings. First, results suggest that more positive learning behaviors at school entry mediate effects of teacher-child interactions in preschool on second-grade achievement. Second, these effects varied by parental socioeconomic status (SES) indicating that low-SES children benefited the most. The findings highlight the role of preschool classroom environments in shaping the school readiness of children with socioeconomic risk factors.

'[ ] the situation in the schools still remains the Achilles heel.' Barriers to the implementation of school tobacco policies-a qualitative study from local stakeholder's perspective in seven European cities.

School tobacco policies (STPs) are a crucial strategy to reduce adolescents smoking. Existing studies have investigated STPs predominantly from a school-related 'insider' view. Yet, little is known about barriers that are not identified from the 'schools' perspective', such as perceptions of local stakeholders. Forty-six expert interviews from seven European cities with stakeholders at the local level (e.g. representatives of regional health departments, youth protection and the field of addiction prevention) were included. The analysis of the expert interviews revealed different barriers that should be considered during the implementation of STPs. These barriers can be subsumed under the following: (i) Barriers regarding STP legislature (e.g. inconsistencies, partial bans), (ii) collaboration and cooperation problems between institutions and schools, (iii) low priority of smoking prevention and school smoking bans, (iv) insufficient human resources and (v) resistance among smoking students and students from disadvantaged backgrounds. Our findings on the expert's perspective indicate a need to enhance and implement comprehensive school smoking bans. Furthermore, collaboration and cooperation between schools and external institutions should be fostered and strengthened, and adequate human resources should be provided.

Participation, supports, and barriers of Korean children and youth with and without disabilities in the school environment.

Background: This study compared participation patterns of Korean children with and without disabilities at school and examined perceived environmental supports and barriers to their school participation.Methods: One hundred eighty four parents of Korean children, aged 5 to 13 years, with and without disabilities completed the Korean Participation and Environment Measure for Children and Youth. The item-level scores of Korean Participation and Environment Measure for Children and Youth were compared between children with and without disabilities using Analysis of covariance and Pearson chi-square tests.Results: In comparison with typically developing children, children with disabilities were less frequently participated and involved and their parents were more likely to desire the change of children's participation in all school activities. Parents of children with disabilities reported that child's physical, cognitive, and social demands, relationship with peers, programs and services, policies and procedures, and money are environmental barriers and personal and public transportation are environmental supports to school participation.Conclusions: Findings help to better understand school participation patterns of Korean children with disabilities and environmental supports and barriers to their participation. The knowledge can be used to support collaboration among school-related professionals for successful participation of children with disabilities at school.Implications for rehabilitationParents of children with disabilities need to focus on both how many times their children participate in school activities and how they get involved in those activities.Educators and therapists should consider in which types of change in school participation parents of children with disabilities are interested to select target activities and to modify them for successful school participation.Educators, therapists, and parents of children with disabilities should analyze the poor fits between functional limitation of children with disabilities and the physical, cognitive, and social demands of school activities for successful school participation.Using information about school participation patterns and environmental supports/barriers can support to better understand children with disabilities and strengthen partnerships among educators, therapists, and parents of children with disabilities for successful inclusion into school contexts.

State School Policies as Predictors of Physical and Mental Health: A Natural Experiment in the REGARDS Cohort.

We used differences in state school policies as natural experiments to evaluate the joint influence of educational quantity and quality on late-life physical and mental health. Using US Census microsample data, historical measures of state compulsory schooling and school quality (term length, student-teacher ratio, and attendance rates) were combined via regression modeling on a scale corresponding to years of education (policy-predicted years of education (PPYEd)). PPYEd values were linked to individual-level records for 8,920 black and 14,605 white participants aged ≥45 years in the Reasons for Geographic and Racial Differences in Stroke study (2003-2007). Linear and quantile regression models estimated the association between PPYEd and Physical Component Summary (PCS) and Mental Component Summary (MCS) from the Short Form Health Survey. We examined interactions by race and adjusted for sex, birth year, state of residence at age 6 years, and year of study enrollment. Higher PPYEd was associated with better median PCS (ß = 1.28, 95% confidence interval (CI): 0.40, 1.49) and possibly better median MCS (ß = 0.46, 95% CI: -0.01, 0.94). Effect estimates were higher among black (vs. white) persons (PCS × race interaction, ß = 0.22, 95% CI: -0.62, 1.05, and MCS × race interaction, ß = 0.18; 95% CI: -0.08, 0.44). When incorporating both school quality and duration, this quasiexperimental analysis found mixed evidence for a causal effect of education on health decades later.

Assessment of Online Resources for Returning to School During and After Treatment of Childhood Cancer.

To evaluate current online parent education resources for children returning to school after a cancer diagnosis. Online search was conducted using 3 search engines and terms recommended by affected families. Sites were evaluated by 3 reviewers for understandability and actionability (scored 0-100%) using the Patient Education Materials Assessment Tool (PEMAT). Readability was assessed using Flesch-Kincaid (grade K-12) and content comprehensiveness by a clinical expert review for 5 late effect domains (scored 0-100%). A total of 56 unique online resources were evaluated. Mean understandability and actionability scores were 54% (range 17-83) and 36% (range 0-83) respectively. The mean Flesch-Kincaid grade level was 10th grade (mode 12th). Comprehensiveness of domain coverage was 34% (mode 20%). Some high-quality materials for this topic are available, but generally low scores on the PEMAT scales and high reading level estimates on Flesch-Kincaid indicate parents may have difficulty understanding and using the information. The low scores for comprehensiveness of information indicate parents will likely need to access multiple sources for complete information. A table provides the names, website (URL), and scoring for the 24 top-rated sites and can be used to make recommendations to parents with improved confidence in quality.

School-Clinic Care Coordination for Youth with ASD: A National Survey of School Psychologists.

Many youth with autism spectrum disorder (ASD) may benefit from interdisciplinary care coordination. Communication and collaboration between the school and clinic settings is particularly important when youth with ASD are receiving both special education and clinic-based services. The responsibility of initiating coordinated care has historically been with the medical home (e.g., primary care clinicians), however, educational professionals (e.g., school psychologists) are also well positioned to assume a leadership role in care coordination. Little is known about the current state, feasibility, or effectiveness of school psychologists leading care coordination efforts. The current study utilizes a mixed-method approach to understand school psychologists' engagement in interdisciplinary collaboration across settings, a central tenet to coordinated care, in providing services to youth with ASD.

The contribution of school safety to weight-related health behaviors for transgender youth.

INTRODUCTION: The aim of the present study is to examine gender identity disparities in different kinds of weight-related health behaviors, including physical activity, participation in physical education at school, and healthy and unhealthy eating habits, and to investigate the relationship between school safety and such behaviors in a sample of transgender and non-transgender students. METHOD: We analyzed a statewide sample of 31,609 students (Mage = 14.04, SD = 1.70; 1.1% transgender). We used multilevel regression models to examine the interactive effects of gender identity and perceptions of school safety on the 4 different outcome variables (physical activity, physical education, healthy and unhealthy eating habits). All models included student- and school-level characteristics as controls. RESULTS: Findings indicated that transgender students, when compared to non-transgender students, reported (a) feeling less safe at school; (b) more physical activity, but less participation in physical education at school; and (c) both more healthy as well as unhealthy eating behaviors. Adjusted regression models showed a significant interaction between gender identity and perceived school safety on healthy eating behaviors; simple slopes indicated that transgender students have healthier eating behaviors when the school context is perceived as safe compared to those who perceived the school as less safe. CONCLUSIONS: School interventions are needed to improve school safety for transgender youth and to reduce gender identity-related disparities in healthy eating and physical activity. Research implications and limitations are discussed.

Gender gaps in cognitive and social-emotional skills in early primary grades: Evidence from rural Indonesia.

This paper examines the magnitude and source of gender gaps in cognitive and social-emotional skills in early primary grades in rural Indonesia. Relative to boys, girls score more than 0.17 SD higher in tests of language and mathematics (cognitive skills) and between 0.18 and 0.27 SD higher in measures of social competence and emotional maturity (social-emotional skills). We use Oaxaca-Blinder decomposition to investigate the extent to which gender differences in early schooling and parenting practices explain these gender gaps in skills. For cognitive skills, differences in early schooling between boys and girls explain between 9% and 11% of the gender gap whereas differences in parenting practices explain merely 3%-5% of the gender gap. This decomposition result is driven largely by children living in villages with high-quality preschools. In contrast, for social-emotional skills, differences in parenting styles toward boys and girls explain between 13% and 17% of the gender gap, while differences in early schooling explain only 0%-6% of the gender gap.

Emergency Action Plans in Secondary Schools: Barriers, Facilitators, and Social Determinants Affecting Implementation.

CONTEXT: Secondary schools (SSs) inconsistently adopt emergency action plans (EAPs) for athletics. OBJECTIVE: To describe the barriers, facilitators, and social determinants influencing EAP adoption in SSs in the United States. DESIGN: Cross-sectional study. SETTING: Secondary schools. PATIENTS OR OTHER PARTICIPANTS: A national sample of athletic trainers (ATs; n = 9642) and athletic directors (ADs; n = 9687) were invited to participate in a Web-based questionnaire. A total of 1273 (13.2%) ATs and 702 (9.2%) ADs responded to the survey. MAIN OUTCOME MEASURE(S): The questionnaire addressed self-reported barriers to, facilitators of, and social determinants (eg, locale, funding classification [eg, public or private SS]) of EAP adoption. The responses of ATs and ADs were analyzed separately. Barriers, facilitators, and social determinants were evaluated using descriptive statistics. Contingency (2 × 2) tables were used to calculate the odds ratios (ORs) of adopting an EAP and the presence of each social determinant. RESULTS: Perceived barriers to implementation were a lack of knowledge about how to implement an EAP and financial limitations. Facilitators were having access to health care personnel, state mandates, and support from a person in an authoritative position. Compared with ATs at rural schools, ATs at suburban schools displayed greater odds of having an EAP (χ2 = 5.63, P = .01, OR = 1.63 [95% confidence interval = 1.08, 2.44]). According to the ADs' responses, a larger SS enrollment (≥500) led to greater odds of adopting an EAP (OR = 2.02 [95% confidence interval = 1.41, 2.89]). CONCLUSIONS: Perceived barriers to EAP adoption suggest that ATs and ADs need to be educated so they can provide additional information on the low cost of EAP adoption. Further, ADs described state mandates as facilitators to improve EAP adoption; therefore, efforts to educate state leaders about the need for mandated policies may be warranted. Certain social determinants (eg, school enrollment) may affect EAP adoption, but not every proposed determinant significantly affected adoption.

Percepções da integração ensino-serviço-comunidade: contribuições para a formação e o cuidado integral em saúde / Perceptions of teaching-service-community integration: contributions to health education and to comprehensive healthcare / Percepciones de la integración enseñanza-servicio-comunidad: contribuciones para la formación y el cuidado integral en salud

O presente estudo objetiva conhecer a percepção dos sujeitos no processo de ensino-aprendizagem-cuidado no Sistema Único de Saúde (SUS), com base no perfil profissional e nas competências e habilidades recomendadas nas Diretrizes Curriculares Nacionais (DCNs) dos cursos de graduação da saúde. Trata-se de pesquisa qualitativa realizada por meio de técnicas de entrevista não diretiva e grupos focais, envolvendo 42 participantes, sendo: professores, estudantes e gestores das instituições de ensino além de usuários, profissionais e gestores da Secretaria Municipal de Promoção de Saúde (SEMUS). A percepção dos diferentes sujeitos que produzem e vivenciam a integração ensino-serviço-comunidade (IESC) revela afinidade com o perfil profissional e com as competências e habilidades comuns recomendadas nas DCNs dos cursos de graduação da área da saúde. A IESC é compreendida como espaço necessário para a efetivação das DCNs e para se alcançar o perfil profissional proposto.(AU)

The study aims to investigate the perception of subjects in the teaching-learning-care process within the Brazilian National Health System (SUS), based on the professional profile and on the skills and competencies recommended by the National Curricular Guidelines (DCNs) for undergraduate programs in the area of health. It is a qualitative research carried out through non-directive interviews and focus groups, involving 42 participants: teachers, students and managers of education institutions, as well as users, professionals and managers of the Municipal Health Promotion Department (SEMUS). The perception of different subjects who produce and experience teaching-service-community integration (TSCI) reveals affinity with the professional profile and with the common skills and competencies recommended by the DCNs. TSCI is understood as a necessary space for the fulfilment of the DCNs and of the proposed professional profile.(AU)

El presente estudio tiene el objetivo de conocer la percepción de los sujetos en el proceso de enseñanza-aprendizaje-cuidado en el Sistema Brasileño de Salud (SUS), con base en el perfil profesional y en las competencias y habilidades recomendadas en las Directrices Curriculares Nacionales (DCNs) de los cursos de graduación de la salud. Se trata de una encuesta cualitativa por medio de técnicas de entrevista no-directiva y grupos focales, envolviendo a 42 participantes, siendo ellos: profesores, estudiantes y gestores de las instituciones de enseñanza, además de usuarios, profesionales y gestores de la Secretaría Municipal de Promoción de Salud (SEMUS). La percepción de los diferentes sujetos que producen y experimentan la integración enseñanza-servicio-comunidad (IESC) revela afinidad con el perfil profesional y con las competencias y habilidades comunes recomendadas en las Directrices Curriculares Nacionales (DCNs) de los cursos de graduación del área de la salud. La IESC se entiende como un espacio necesario para hacer efectivas las DCNs y para alcanzar el perfil profesional propuesto.(AU)

Laws About Transparent School Vaccination Reporting: Public Health Context and Ethics.

In response to a recent surge in vaccine exemptions for school-aged children, advocacy for transparency regarding school vaccination rates has gained momentum in the sphere of public policy and legislation. We explore the public health context for transparency-focused school vaccination reporting laws and recent legislative successes and failures. We then provide an ethical analysis of policy that mandates publicly accessible, granular reporting of school vaccination rates.The ethical justification for this type of policy is robust. Although there is no evidence demonstrating its effects on public health, transparent school vaccination reporting has the potential to enhance individual and public decision-making, especially concerning the protection of children with compromised immune systems. This policy also offers the benefit of preserving the autonomy of parents who choose not to vaccinate their children.Policymakers in all states should support passage of this type of legislation along with other effective vaccination policies, including evidence-based vaccine education for parents who seek exemptions and reimbursement for clinicians who provide vaccine-related counseling.