Parents' or legal guardians' beliefs and attitudes about childhood vaccination: a scoping review.

OBJECTIVE: to map scientific evidence about perceptions, beliefs, knowledge and attitudes of parents or legal guardians of children under 5 years of age regarding routine childhood vaccination. METHODS: a scoping review, conducted in accordance with the JBI framework. The searches were carried out in the PubMed/MEDLINE, Web of Science, Scopus and LILACS databases. A total of 5,535 studies were returned and 77 were selected, which met the inclusion criteria. RESULTS: perceptions related to interaction with healthcare professionals and services, with family organization and structure, with social interaction and public policies, cultural, religious and personal beliefs, knowledge about vaccination schedule, vaccination and immunization process and sources of information are the main factors mapped and which can positively or negatively influence parents' or legal guardians' attitudes towards vaccinating children. CONCLUSIONS: the findings allow us to identify factors related to parents' perception and beliefs about childhood vaccination.

Association between the guardians' educational levels and unintentional injuries in children aged 6-18 in Shenzhen, China.

BACKGROUND: Unintentional injuries is the leading cause of death in children aged 6-18 in China. Previous studies on the association between the guardians' educational levels and unintentional injuries in children have been inconclusive, and it remains unclear among the Chinese population. Therefore, this study aimed to identify the association between guardians' educational levels and unintentional injuries in children aged 6-18 in Shenzhen, China. METHODS: This cross-sectional study enrolled 9,903 children aged 6-18 in Shenzhen in 2020 using a multistage cluster sampling method. Information on the children and guardians were collected, and unintentional injuries in the past year was examined by using two nested questions. Logistic regression analyses were used to test the association between the guardians' educational levels and unintentional injuries in children aged 6-18, and the crude odds ratios (ORs) and adjusted ORs with 95% confidence intervals (95% CI) were calculated. RESULTS: 275 of the 9,903 children reported experiencing at least one unintentional injuries in the past year, and the weighted incidence of unintentional injuries was 6.3% (95% CI: 5.8-6.8%) in children aged 6-18 in Shenzhen, China. The incidence of unintentional injuries differed significantly in the guardians' education levels (P < 0.05). After adjustment for the children's variables, multiple binary logistic regression analysis showed that compared to children whose guardians' educational levels were low, children whose guardians' educational levels were high (adjusted OR = 0.57, 95% CI: 0.37-0.87) and medium (adjusted OR = 0.56, 95% CI: 0.39-0.81) had a lower odds of unintentional injuries. Similar results were also observed when further adjustment for both the children's and guardians' variables. CONCLUSION: The overall incidence of unintentional injuries in children aged 6-18 in Shenzhen was low, and it was associated with the guardians' educational levels. Children whose guardians' educational levels were low should be given special concern to prevent unintentional injuries, and it is suggested to reduce the incidence of unintentional injuries in children by improving the guardians' educational levels.

Palliative Care for Refractory Depressive Symptoms in a Female Veteran Geriatric Patient.

AbstractPsychiatric treatment options, such as electroconvulsive therapy (ECT), can be lifesaving for individuals suffering from severe mental illness. For individuals who are unable to make or communicate their own medical decisions, this decision may fall on a legal guardian, who will make decisions on the patient's behalf. Here we discuss the considerations of end-of-life planning in a patient with severe mental illness under guardianship when treatment modalities, in this case ECT, are no longer effective.

Transcultural Psychiatry in Medical Ethics: Assessing Decision-Making Capacity within the Lens of an East African Refugee.

AbstractA 29-year-old female East African refugee with no formal psychiatric history and a medical history significant for HIV was admitted for failure to thrive and concern for bizarre behavior in the context of abandonment by her husband and separation from her child. After psychiatric evaluation, it was determined that she did not have the capacity to care for herself independently; adult protective services then pursued and was awarded guardianship. While admitted, the patient repeatedly refused medical treatment, had a feeding tube placed for forced nutrition and medications (though she did at one point remove this tube herself), and received two electroconvulsive therapy (ECT) treatments. Soon thereafter, the patient's court-appointed guardian met with the primary medical, psychiatric, and ethics teams to discuss goals of care in the setting of complex social and cultural needs. It was collectively determined that the patient's choices to refuse care (including nutrition, lab work, medications, and ECT) and some repeated behaviors (e.g., denial of divorce, denial of HIV, denial of need for care) could be considered culturally appropriate in the context of the acute stressors leading up to hospitalizations. All teams concluded, therefore, that the patient had the capacity to refuse these interventions and that further forced intervention would pose a greater chance of exacerbating her already-significant trauma history than improving her outcomes. Ultimately, the patient was able to be discharged into the care of her guardian, who would assist her in receiving support from members of her community who share her language and culture.

HPV vaccination intention among guardians of female secondary school students in Chongqing, China.

Background: In China, Chongqing is the first province implement a province-wide HPV vaccination free program for female students. Given the HPV vaccination of adolescents is largely dependent on the intent of their guardians, this study examined the factors associated with the parental intention to vaccinate their daughter against HPV. And we could explore how to change the factors to incentivize more guardians to vaccinate their children.Methods: This study used a cross-sectional survey designed by multi-stage non-randomized sampling. Study participants were guardians of female students of second year of junior high in all districts and counties of Chongqing, who were most knowledgeable about the immunization status of the adolescents. Data was collected by an online survey platform between December, 2022 to March, 2023.Results: We collected 20, 642 valid samples. Among the participating guardians, nearly 40% guardians had never heard of HPV and HPV vaccine. 68.8% guardians considered vaccinating their children against HPV, 12.5% guardians had vaccinated or vaccinating HPV vaccine for their children, and only 16.7% were reluctant to vaccinate for their children right now. Some individual characteristics of guardians (e.g. age, number of the children) were associated with the intention of HPV vaccines. Sufficient knowledge of HPV and HPV vaccine would promote the HPV vaccination, and vaccine hesitancy prevented guardians from vaccinating their children.Conclusions: Majority of guardians held a positive intention to vaccinate their daughter, higher than the foreign uptake. Exploring the methods of social propaganda to promote HPV-related knowledge and reduce the safety concerns of guardians could help improve HPV vaccination intention.

Guardian Reasons for Accessing Their Transgender and Gender-Diverse Adolescent's Patient Portal Account.

PURPOSE: To understand if and why guardians access their adolescent child's electronic health record patient portal account. METHODS: Guardians of transgender and gender-diverse adolescents completed a survey regarding patient portal use. Descriptive statistics were used to describe items related to guardian access to adolescent portal accounts. RESULTS: Of 82 respondents, 37.8% indicated they had used their child's login to access the patient portal. Most indicated they accessed their adolescent's account because their child asked them to do so. Other common reasons included being worried they might miss important health information and not realizing there was a difference between patient and proxy accounts. DISCUSSION: Results of this study provide a more detailed understanding regarding guardian access to adolescent patient portals. Findings can be used to inform adolescent patient portal design and enrollment practices that protect adolescent confidentiality.

Examining the involvement of guardians of children with acute lymphoblastic leukemia in Tanzania as public contributors to inform the design and conduct of the GuardiansCan project: A mixed-methods study protocol.

BACKGROUND: Public contribution in research can lead to the design and conduct of more feasible and relevant research. However, our understanding of the acceptability and feasibility of public contribution and the evidence base regarding its impact in low- and middle-income countries (LMICs) is limited. METHODS: In this study protocol, we describe a mixed-method examination of public contribution activities in the GuardiansCan project. The GuardiansCan project aims to respond to Tanzanian guardians' poor adherence to children's follow-up care after treatment for acute lymphoblastic leukemia (ALL) with the help of Mobile Health technology. We aim to: (1) involve guardians of children treated for ALL as Guardians Advisory Board (GAB) members in the managing and undertaking, analysis and interpretation, and dissemination phases of the GuardiansCan project; and (2) examine the acceptability, feasibility, and perceived impact of GAB members' contribution to the GuardiansCan project from the perspective of the GAB members and public contribution coordinators. We will recruit six to eight guardians of children treated for ALL to the GAB. We will hold workshops where GAB members contribute to all project phases. Using impact logs, we will record GAB workshop activities and the perceived impact of these activities. We will interview GAB members and public contribution coordinators 6 months after establishing the GAB, and at the end of each study within the project, to examine the acceptability, feasibility, and perceived impact of public contribution activities. DISCUSSION: We expect GAB contribution to increase project quality and relevance, and inform how to best embed public contribution in research in LMICs.

Impact of Legal Guardian Absence on Research Enrollment in the PICU.

OBJECTIVES: To identify the frequency of which a legal guardian is at the bedside of children admitted to the PICU that are eligible for research studies. DESIGN: A prospective, observational study. SETTING: Three tertiary Canadian PICUs. PATIENTS: Two hundred one patients were admitted to the PICU between September 2021 and March 2023 (site 1), from March 2019 to March 2020 and March 2022 to March 2023 (site 2), and from March 2019 to March 2020 and July 2020 to November 2021 (site 3). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: At each center, the duration of consent encounters was recorded for patients eligible for research by documenting the length of each attempt (min). The frequency of parental presence at bedside and the ability for a guardian to make a decision were also recorded. Thirty-five percent of patients eligible for research did not have a legal guardian at the bedside on the first attempted consent encounter. Twenty-three percent of approached patients were not enrolled due to an inability for a consent decision to be made by the child's legal guardian or an inability to contact the guardian before discharge. CONCLUSIONS: The absence of legal guardians in the PICU poses a barrier to the enrollment of critically ill children in pertinent research studies and suggests that a model of deferred consent or implied consent would aid in the future of critical care research.

Bloom's taxonomy-Can evidence-based teaching improve junior medical officers' knowledge of the mental health and guardianship acts?

OBJECTIVE: To determine whether a brief educational intervention for Junior Medical Officers (JMOs), using teaching methods aimed at achieving higher outcomes on Bloom's Taxonomy, significantly improved participant confidence and knowledge in decision making about restrictive care. METHOD: JMOs received a teaching session on restrictive medical and mental health care. Groups were randomly assigned to either sessions including a component of modern pedagogical interventions (Think-Pair-Share and SNAPPS), or sessions including a control period focusing on reviewing a condensed summary of relevant information. Pre- and post-intervention measures were recorded for subjective self-ratings of confidence and scores on standardized clinically relevant extended matching questions (EMQs). RESULTS: There was no difference in subjective confidence improvement between groups; however, the group receiving the modern pedagogical intervention demonstrated significantly greater objective performance on knowledge-based EMQs. CONCLUSIONS: A brief modern pedagogical intervention using interactive teaching methods shows promise for improving knowledge of restrictive care and the Mental Health and Guardianship Acts. In the control group, similarly increased confidence in knowledge did not equate to increased competence on a knowledge assessment. Refurbishing educational interventions presents opportunities for improving clinical outcomes and engaging junior doctors in psychiatry.

Using a Large Language Model to Identify Adolescent Patient Portal Account Access by Guardians.

This diagnostic/prognostic study assesses the ability of a large language model (LLM) to detect guardian authorship of messages originating from adolescent patient portals.

Involuntary psychiatric hospitalisation - differences and similarities between patients detained under the mental health act and according to the legal guardianship legislation.

BACKGROUND: Involuntary psychiatric hospitalisation occurs under different legal premises. According to German law, detention under the Mental Health Act (MHA) is possible in cases of imminent danger of self-harm or harm to others, while detention according to the legal guardianship legislation (LGL) serves to prevent self-harm if there is considerable but not necessarily imminent danger. This study aims to compare clinical, sociodemographic and environmental socioeconomic differences and similarities between patients hospitalised under either the MHA or LGL. METHODS: We conducted a retrospective health records analysis of all involuntarily hospitalised cases in the four psychiatric hospitals of the city of Cologne, Germany, in 2011. Of the 1,773 cases, 87.3% were detained under the MHA of the federal state of North Rhine-Westphalia and 6.4% were hospitalised according to the federal LGL. Another 6.3% of the cases were originally admitted under the MHA, but the legal basis of detention was converted to LGL during the inpatient psychiatric stay (MHA→LGL cases). We compared sociodemographic, clinical, systemic and environmental socioeconomic (ESED) variables of the three groups by means of descriptive statistics. We also trained and tested a machine learning-based algorithm to predict class membership of the involuntary modes of psychiatric inpatient care. RESULTS: Cases with an admission under the premises of LGL lived less often on their own, and they were more often retired compared to MHA cases. They more often had received previous outpatient or inpatient treatment than MHA cases, they were more often diagnosed with a psychotic disorder and they lived in neighbourhoods that were on average more socially advantaged. MHA→LGL cases were on average older and more often retired than MHA cases. More often, they had a main diagnosis of an organic mental disorder compared to both MHA and LGL cases. Also, they less often received previous psychiatric inpatient treatment compared to LGL cases. The reason for detention (self-harm or harm to others) did not differ between the three groups. The proportion of LGL and MHA cases differed between the four hospitals. Effect sizes were mostly small and the balanced accuracy of the Random Forest was low. CONCLUSION: We found some plausible differences in patient characteristics depending on the legal foundation of the involuntary psychiatric hospitalisation. The differences relate to clinical, sociodemographic and socioeconomical issues. However, the low effect sizes and the limited accuracy of the machine learning models indicate that the investigated variables do not sufficiently explain the respective choice of the legal framework. In addition, we found some indication for possibly different interpretation and handling of the premises of the law in practice. Our findings pose the need for further research in this field.

Diverging medical and legal perceptions of the need for legal guardianship in people with dementia: A qualitative study.

BACKGROUND: Dementia is assumed to alter mental capacity, which may necessitate legal guardianship. However, only limited research exists on how dementia affects mental capacity, and most studies have focused solely on a medical perspective and concentrate on memory functions. The aim of this qualitative study was to investigate physicians' and legal experts' perceptions on a broad range of cognitive and neuropsychiatric domains potentially affecting mental capacity and the need for guardianship in people with dementia. METHODS: Physicians (N = 30) and legal experts (N = 20) participated in semi-structured individual interviews. The data were analyzed by using content analysis and further semi-quantified according to the cognitive and neuropsychiatric domains. RESULTS: Physicians considered neuropsychiatric symptoms and executive dysfunction to be the most important deficits in the legal context, while legal experts highlighted episodic memory impairment and dyscalculia. Perceptions regarding the importance of several cognitive and neuropsychiatric symptoms varied between and within the professional groups. CONCLUSIONS: Physicians and legal experts diverged in their perceptions of cognitive and neuropsychiatric domains affecting mental capacity and the need for guardianship. The evaluation and influence of medical evidence among legal experts heavily rely on subjective opinions. Given the substantial potential impact on patients' equal access to their rights, developing standardized guidelines is essential.

Minors' and guardian access to and use of a national patient portal: A retrospective comparative case study of Sweden and Finland.

BACKGROUND: Approaches to implementing online record access (ORA) via patient portals for minors and guardians vary internationally, as more countries continue to develop patient-accessible electronic health records (PAEHR) systems. Evidence of ORA usage and country-specific practices to allow or block minors' and guardians' access to minors' records during adolescence (i.e. access control practices) may provide a broader understanding of possible approaches and their implications for minors' confidentiality and guardian support. AIM: To describe and compare minors' and guardian proxy users' PAEHR usage in Sweden and Finland. Furthermore, to investigate the use of country-specific access control practices. METHODS: A retrospective, observational case study was conducted. Data were collected from PAEHR administration services in Sweden and Finland and proportional use was calculated based on population statistics. Descriptive statistics were used to analyze the results. RESULTS: In both Sweden and Finland, the proportion of adolescents accessing their PAEHR increased from younger to older age-groups reaching the proportion of 59.9 % in Sweden and 84.8 % in Finland in the age-group of 17-year-olds. The PAEHR access gap during early adolescence in Sweden may explain the lower proportion of users among those who enter adulthood. Around half of guardians in Finland accessed their minor children's records in 2022 (46.1 %), while Swedish guardian use was the highest in 2022 for newborn children (41.8 %), and decreased thereafter. Few, mainly guardians, applied for extended access in Sweden. In Finland, where a case-by-case approach to access control relies on healthcare professionals' (HCPs) consideration of a minor's maturity, 95.8 % of minors chose to disclose prescription information to their guardians. CONCLUSION: While age-based access control practices can hamper ORA for minors and guardians, case-by-case approach requires HCP resources and careful guidance to ensure equality between patients. Guardians primarily access minors' records during early childhood and adolescents show willingness to share their PAEHR with parents.

Considerations for Alternative Decision-Making When Transitioning to Adulthood for Youth With Intellectual and Developmental Disabilities: Policy Statement.

With advances in medical care, more youth with intellectual and/or developmental disabilities (IDD) are transitioning into adulthood. Patient- and family-centered, integrated care is warranted around this time of transition. Support teams (including the youth, caregivers, teachers, and pediatricians) should engage in transition planning, ideally starting between 12 and 14 years of age, to identify and develop resources to support the maturing youth's capacity for independent decision-making. Care teams should consider the varied levels of alternative decision-making support, which may include supported decision-making, medical proxy decision-making, power of attorney, and/or establishment of legal guardianship arrangements, to support the youth's health and well-being optimally. Ultimately, if independent decision-making is not appropriate, the goal for youth with IDD should be the least restrictive alternative, while preserving human rights and human dignity and promoting their autonomy. These considerations review alternative decision-making support, concepts, and legal requirements available for youth with IDD and their care teams. Pediatricians can support youth with IDD and their families in the transition process and decision-making autonomy by actively engaging the youth in care decisions, supporting needs for augmentative communication, fostering their expression of preferences and understanding of care decisions, and linking them to resources such as the medical-legal partnership model.

Evaluating Health Literacy in Families of Injured Children: A Prospective Observational Cohort Study at a Level One Pediatric Trauma Center.

BACKGROUND: Low health literacy (HL) has been associated with poor health outcomes in children. Optimal recovery after pediatric injury requires caregiver participation in complicated rehabilitative and medical aftercare. We aimed to quantify HL among guardians of injured children and identify factors associated with low HL of guardians. METHODS: A prospective observational cohort study was conducted to evaluate the HL using the Newest Vital Sign™ of guardians of injured children (≤18 years) admitted to a level 1 pediatric trauma center. Patient and guardian characteristics were compared across levels of HL using univariate statistics. We conducted multivariable logistic regression to identify factors independently-associated with low HL. RESULTS: A sample of 95 guardian-child dyads were enrolled. The majority of guardians had low HL (n = 52, 55%), followed by moderate HL (n = 36, 38%) and high HL (n = 7, 7%). Many families received public benefits (n = 47, 49%) and 12 guardians (13%) had both housing and employment insecurity. Guardians with low HL were significantly more likely to have insecure housing and not have completed any college. CONCLUSION: The majority of injured children had a primary guardian with low HL. Pediatric trauma centers should consider screening for low HL to ensure that families have adequate post-discharge support. LEVEL OF EVIDENCE: Level 3.

On legal guardianship: An exploratory assessment of knowledge, attitudes and practices of resident physicians.

BACKGROUND: Clinicians encounter patients under legal guardianship. We aimed to assess the knowledge, attitudes and practices (KAP) on legal guardianship in residents. METHODS: A KAP pilot survey about legal guardianship was developed by an interdisciplinary medicine-law-public health team and was distributed via institutional email to internal medicine, psychiatry, and neurology residents in a single academic institution. RESULTS: Of the 172 invited residents, 105 (61%) responded and 102 surveys were included in the final analysis. Most respondents (58% women; internal medicine 73%, neurology 15%, psychiatry 12%) had attended 42 medical schools from 16 countries and had heard about guardianship (88%), but only 23% reported having received training on guardianship during medical school or residency. The vast majority (97%) understood the intended benefit of guardianship, but only 22.5% reported knowing that guardianship removed an individual's decision-making rights. Nearly half (47%) of respondents reported never having asked for documentation to prove that an individual was a patient's guardian, and only 15% expected to see a court order as proof of guardianship status. CONCLUSIONS: Although most residents intuitively understood the intended benefit of guardianship, they did not understand its full implications for clinical practice. Training interventions are warranted.

Preventing Abuses in Guardianship Cases.

Guardianships allow court-appointed guardians to make decisions on behalf of persons who are incapable of caring for themselves. With their authority frequently extending over both the personal and the financial affairs of a ward, guardians sometimes abuse their extensive powers. Misuse of funds, excessive fees, and neglect of the ward's needs all have been seen in guardianship cases. As awareness of this problem has grown, innovative approaches have been developed to prevent and detect abuses, including mandatory certification, centralized audits, and visits to persons under guardianship to assess their status. Funding such efforts, however, remains a challenge.

[Guardianship law - what doctors and patients should know about the latest amendment]. / Das reformierte Betreuungsrecht und die Folgen für die Arztpraxis.

With the latest amendment of the guardianship law the German legislator means to strengthen the patients' right of self-determination. The most significant new regulations are the introduction of mutual legal representation of married couples in emergency and changes restricting the guardian's legal position. New challenges for doctors and lawyers arise especially from the legal representation of married couples. General practitioners who advise their patients with the preparation of provision documents should particularly explain the importance of recordations in the central providing register (ZVR).

Diversified caregiver input to upgrade the Young Children's Participation and Environment Measure for equitable pediatric re/habilitation practice.

BACKGROUND: Practitioner and family experiences of pediatric re/habilitation can be inequitable. The Young Children's Participation and Environment Measure (YC-PEM) is an evidence-based and promising electronic patient-reported outcome measure that was designed with and for caregivers for research and practice. This study examined historically minoritized caregivers' responses to revised YC-PEM content modifications and their perspectives on core intelligent virtual agent functionality needed to improve its reach for equitable service design. METHODS: Caregivers were recruited during a routine early intervention (EI) service visit and met five inclusion criteria: (1) were 18 + years old; (2) identified as the parent or legal guardian of a child 0-3 years old enrolled in EI services for 3 + months; (3) read, wrote, and spoke English; (4) had Internet and telephone access; and (5) identified as a parent or legal guardian of a Black, non-Hispanic child or as publicly insured. Three rounds of semi-structured cognitive interviews (55-90 min each) used videoconferencing to gather caregiver feedback on their responses to select content modifications while completing YC-PEM, and their ideas for core intelligent virtual agent functionality. Interviews were transcribed verbatim, cross-checked for accuracy, and deductively and inductively content analyzed by multiple staff in three rounds. RESULTS: Eight Black, non-Hispanic caregivers from a single urban EI catchment and with diverse income levels (Mdn = $15,001-20,000) were enrolled, with children (M = 21.2 months, SD = 7.73) enrolled in EI. Caregivers proposed three ways to improve comprehension (clarify item wording, remove or simplify terms, add item examples). Environmental item edits prompted caregivers to share how they relate and respond to experiences with interpersonal and institutional discrimination impacting participation. Caregivers characterized three core functions of a virtual agent to strengthen YC-PEM navigation (read question aloud, visual and verbal prompts, more examples and/or definitions). CONCLUSIONS: Results indicate four ways that YC-PEM content will be modified to strengthen how providers screen for unmet participation needs and determinants to design pediatric re/habilitation services that are responsive to family priorities. Results also motivate the need for user-centered design of an intelligent virtual agent to strengthen user navigation, prior to undertaking a community-based pragmatic trial of its implementation for equitable practice.