Diagnosis of sleep disorders in child healthcare settings.

OBJECTIVES: Sleep disorders impact at least 10 % of children, pose risks to overall wellbeing, and are key targets of preventive interventions. The objectives of this study were to describe the prevalence of pediatric sleep disorder diagnoses across sociodemographic characteristics and co-occurring conditions, and to explore potential sociodemographic disparities. METHODS: Cross-sectional analysis of 12,394,902 children (0-17 years; 50.9 % Medicaid-insured) in the 2017 MarketScan database. Prevalence was assessed utilizing ICD-10 codes, with multivariate logistic regressions examining disparities (insurance coverage; race and ethnicity in Medicaid-insured) for diagnoses in ≥0.10 % of children. RESULTS: The prevalence of sleep disorder diagnoses was 2.36 %. The most common diagnoses were obstructive sleep disordered breathing (oSDB, 1.17 %), unspecified sleep disorders (0.64 %), insomnia (0.52 %), and other SDB (0.10 %), with <0.10 % for all other diagnoses. Insomnia and parasomnias diagnoses were much lower than diagnostic estimates. Sleep diagnoses were more prevalent in Medicaid versus commercially insured youth, 2-5-year-olds, and in children with co-occurring medical, neurodevelopmental, or behavioral health conditions. Girls and boys were generally equally likely to be diagnosed with any sleep disorder. In Medicaid-insured children, white children were more likely to have any sleep diagnosis compared to all other racial and ethnic groups. Black/African American children were more likely than white children to have oSDB. CONCLUSIONS: Compared to diagnostic estimates, claims data suggest sleep disorders are under-diagnosed, with notable sociodemographic disparities. Findings suggest a need for clinical resources to identify and address sleep disorders and to understand biases potentially driving disparities, given that sleep is a modifiable determinant of child wellbeing.

Assessing Sustainability Factors for Rural Household Sanitation Coverage in Bhutan, Kenya, Nepal, and Zambia: A Qualitative Analysis.

BACKGROUND: Few countries are likely to achieve universal sanitation within the next decade as sustaining household sanitation coverage remains a critical challenge. This study aimed to investigate factors that may have supported or hindered sustainability of sanitation coverage 1-2 years after the completion of an integrated, area-wide sanitation program in 4 countries. METHODS: We conducted qualitative analyses to identify factors related to the sustainability of sanitation coverage in Bhutan, Kenya, Nepal, and Zambia, 2 years after completion of the Sustainable Sanitation and Hygiene for All program. From November 2019 to March 2020, we conducted focus group discussions and key informant interviews with community members, project implementers, and decision makers. We triangulated the qualitative findings with data from household surveys to characterize subnational sanitation coverage throughout implementation and 1-2 years after. RESULTS: Our data revealed behavioral, contextual, and service delivery factors that were related to the sustainability of sanitation improvements. Service delivery factors included follow-up hygiene promotion, access to construction materials, local government commitment postimplementation, functioning monitoring systems, private sector uptake of supply chain improvements, and capacity for innovation. Contextual and behavioral factors included poverty, soil type, road networks, social cohesion, desire for improved latrines, maintenance and cleaning, and knowledge of sanitation benefits. CONCLUSION: The presence or absence of sustainability factors identified through this research may have implications on where certain programmatic approaches will work and where adaptations may be required. By comparing sustainability factors with subnational slippage rates, we were able to illustrate how local service delivery systems may respond to barriers and enablers. Understanding the programmatic and contextual factors that either drive or hinder long-term sanitation coverage may allow for greater program impact through adapting implementation based on existing challenges in service delivery and context.