Telehealth utilization barriers among Alabama parents of pediatric patients during COVID-19 outbreak.

BACKGROUND: Telehealth can improve access to evidence-based care at a lower cost for patients, especially those living in underserved and remote areas. The barriers to the widespread adoption of telehealth have been well documented in the literature. However, the barriers may not be the same for pediatric patients, who must rely on their parents or guardians to make healthcare decisions. This paper presents some of the leading barriers parents or guardians of pediatric patients report in using telehealth to meet their children's healthcare needs. METHODS: This cross-sectional survey was conducted in a tertiary care pediatric Emergency Department (ED) at a children's hospital in Alabama between September 2020 to December 2020. The parents or guardians of pediatric patients were asked about their reasons for not using telehealth despite having healthcare needs for their children, whether they canceled or rescheduled healthcare provider visits and facility visits, and whether the child's health conditions changed over the past three months. Descriptive analyses were conducted that explored the distribution of telehealth use across the variables listed above. RESULTS: Five hundred ninety-seven parents or guardians of pediatric patients participated in the survey, and 578 answered the question of whether they used telehealth or not over the past three months. Of them, 33.1% used telehealth, 54.3% did not, and 12.6% did not have healthcare needs for their child. The leading reason for not using telehealth was that the doctor or health provider did not give them a telehealth option, the second main reason was that they did not know what telehealth is, and the third leading reason was that the parents did not think telehealth would help meet healthcare needs for their child. CONCLUSIONS: This study highlights the telehealth utilization barriers among underserved pediatric populations, including the need for physicians to proactively offer telehealth options to parents or guardians of pediatric patients. Improving health literacy is of paramount importance, given that a substantial proportion of parents were not familiar with telehealth. Policymakers and healthcare organizations should raise awareness about the benefits of telehealth which can improve healthcare access for underserved pediatric patients.

MCH Workforce Capacity: Maximizing Opportunities Afforded by a Changing Public Health System.

Objectives A skilled workforce is essential to advancing maternal and child health (MCH) in a rapidly changing public health system. Little is known about the MCH workforce's existing capacity to maximize opportunities afforded by ongoing change. We assessed MCH workforce capacity in three areas: Systems Integration, Evidence-Based Decision-Making, and Change Management/Adaptive Leadership. We then examined associations between workforce capacity and modifiable workforce development strategies/resources. Methods Data are from the Public Health Workforce Interests and Needs Survey (PH WINS). The present study was limited to employees working in MCH programs (weighted N = 3062). Workforce capacity was operationalized as self-reported awareness of public health trends and proficiency to perform related skills in the three areas. Survey-weighted generalized estimating equations were used to fit logistic regression models accounting for employee clustering within states. Results While awareness of public health trends was low, the majority of employees (> 70% in each area) reported proficiency to perform skills related to these trends. Capacity was lowest in Systems Integration. Employee engagement in academic partnerships and higher state contributions to MCH program budgets were the strategies/resources most consistently associated with higher capacity. Workplace support was the strongest correlate of capacity in Change Management/Adaptive Leadership. Conclusions for Practice Although employees lacked familiarity with specific public health trends, they were proficient in skills needed to engage in related work. Still, areas for improvement remain. Results provide a baseline against which future training efforts can be evaluated. Academic partnerships and MCH program funding may be useful to prioritize in the context of health transformation.

An Examination of the Perceived Importance and Skills Related to Policies and Policy Making Among State Public Health Injury Prevention Staff.

OBJECTIVE: The purpose of this research is to use the Public Health Workforce Interests and Needs Survey to assess in greater detail state injury prevention staff perceptions of policy development and related skills and their awareness and perception of "Health in All Policies" (HiAP). DESIGN: The Public Health Workforce Interests and Needs Survey gauged public health practitioners' perspectives on workplace environment, job satisfaction, national trends, and training needs, and gathered demographics on the workforce. This study utilizes data from the state health agency frame only, focusing solely on those permanently employed, central office staff in injury prevention. Respondents were sampled from 5 paired Health and Human Services regions. SETTING/PARTICIPANTS: Approximately 25 000 invitations were sent to central office employees. The response rate was 46% (n = 10 246). The analysis in this article includes only injury prevention employees with programmatic roles, excluding clerical and custodial staff, providing us with a total of 97 respondents. When weighted, this resulted in a weighted population size of 365 injury prevention workers. MAIN OUTCOME MEASURES: The main outcome measures include demographics, responses to understanding of and skill levels related to policy development, and perceptions of HiAP public health trend. RESULTS: State injury prevention workers reported lower policy-making skill but had an overall appreciation of the importance of policies. In general, state injury prevention workers heard of HiAP, thought there should be more emphasis on it, but did not think that HiAP would have an impact on their day-to-day work. CONCLUSIONS/IMPLICATIONS FOR POLICY AND PRACTICE: Efforts are needed for all state injury prevention workers to become better skilled in policy development, implementation, and evaluation in order to become stronger injury prevention advocates and role models.

Autism spectrum disorder prevalence and associations with air concentrations of lead, mercury, and arsenic.

Lead, mercury, and arsenic are neurotoxicants with known effects on neurodevelopment. Autism spectrum disorder (ASD) is a neurodevelopmental disorder apparent by early childhood. Using data on 4486 children with ASD residing in 2489 census tracts in five sites of the Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring (ADDM) Network, we used multi-level negative binomial models to investigate if ambient lead, mercury, and arsenic concentrations, as measured by the US Environmental Protection Agency National-Scale Air Toxics Assessment (EPA-NATA), were associated with ASD prevalence. In unadjusted analyses, ambient metal concentrations were negatively associated with ASD prevalence. After adjusting for confounding factors, tracts with air concentrations of lead in the highest quartile had significantly higher ASD prevalence than tracts with lead concentrations in the lowest quartile (prevalence ratio (PR) = 1.36; 95 '% CI: 1.18, 1.57). In addition, tracts with mercury concentrations above the 75th percentile (>1.7 ng/m(3)) and arsenic concentrations below the 75th percentile (≤0.13 ng/m(3)) had a significantly higher ASD prevalence (adjusted RR = 1.20; 95 % CI: 1.03, 1.40) compared to tracts with arsenic, lead, and mercury concentrations below the 75th percentile. Our results suggest a possible association between ambient lead concentrations and ASD prevalence and demonstrate that exposure to multiple metals may have synergistic effects on ASD prevalence.

Autism spectrum disorder prevalence and proximity to industrial facilities releasing arsenic, lead or mercury.

Prenatal and perinatal exposures to air pollutants have been shown to adversely affect birth outcomes in offspring and may contribute to prevalence of autism spectrum disorder (ASD). For this ecologic study, we evaluated the association between ASD prevalence, at the census tract level, and proximity of tract centroids to the closest industrial facilities releasing arsenic, lead or mercury during the 1990s. We used 2000 to 2008 surveillance data from five sites of the Autism and Developmental Disabilities Monitoring (ADDM) network and 2000 census data to estimate prevalence. Multi-level negative binomial regression models were used to test associations between ASD prevalence and proximity to industrial facilities in existence from 1991 to 1999 according to the US Environmental Protection Agency Toxics Release Inventory (USEPA-TRI). Data for 2489 census tracts showed that after adjustment for demographic and socio-economic area-based characteristics, ASD prevalence was higher in census tracts located in the closest 10th percentile compared of distance to those in the furthest 50th percentile (adjusted RR=1.27, 95% CI: (1.00, 1.61), P=0.049). The findings observed in this study are suggestive of the association between urban residential proximity to industrial facilities emitting air pollutants and higher ASD prevalence.

The relationship between state abortion-restrictions and homicide deaths among children under 5 years of age: a longitudinal study.

The purpose of this study is to explore whether, in the U.S., there are associations between state-level variations in mortality among young children and state abortion restriction policies - such as parental-consent requirements, parental-notification requirements, mandatory delay laws, and restrictions on Medicaid funding for abortion. To investigate this, we used NCHS Multiple Cause of Deaths public-use data files for the period 1983-2002, and compiled data on children ages 0-4 identified as having died as a result of assault/homicide in each state and year. Medicaid funding of abortion, mandatory delay laws, and parental involvement laws for minors seeking abortions were included as the main predictor variables of interest. Multivariate count data models using pooled state-year-age cohort data, with state and time fixed effects and other state-level controls, were estimated. Results indicated that, between 1983 and 2002, the average increase in the number of homicide deaths for children under 5 years of age was 5.70 per state among states that implemented stricter abortion policies over that time, and 2.00 per state for states that did not. In the count data models, parental-consent laws were associated with a 13 percent increase in child homicide deaths; parental-notification laws were associated with an 8 percent increase in child homicide deaths though the results were less robust to alternate model specifications; mandatory delay requirements were associated with a 13 percent increase in child homicide deaths. While these data do not allow us to discern precise pathways via which state abortion-restrictions can lead to more child homicide deaths, we speculate that state restrictions on abortion may result in a disproportionate increase in children born into relatively high-risk environments. Additional research is called for to explore the association of state abortion-restrictions with other measures of infant/child health and well-being.

Racial disparities in perinatal outcomes and pregnancy spacing among women delaying initiation of childbearing.

INTRODUCTION: Reducing racial/ethnic disparities is a key objective of the Healthy People 2010 initiative. Unfortunately, racial disparities among women delaying initiation of childbearing have received limited attention. As more women in the US are delaying initiation of childbearing, it is important to examine racial disparities in reproductive health outcomes for this subgroup of women. OBJECTIVE: To examine racial disparities in perinatal outcomes, interpregnancy interval, and to assess the risk for adverse outcomes in subsequent pregnancy for women delaying initiation of childbearing until age 30 or older compared to those initiating childbearing at age 20-29. METHODS: We conducted a retrospective cohort study using the Missouri maternally linked cohort files 1978-1997. Final study sample included 239,930 singleton sibling pairs (Whites and African Americans). Outcome variables included first and second pregnancy outcomes (fetal death, low birth weight, preterm delivery and small-for-gestational age) and interpregnancy interval between first and second pregnancy. Independent variables included maternal age at first pregnancy and race. Analysis strategies used involved stratified analyses and multivariable unconditional logistic regression; interactions between maternal race, age and interpregnancy interval were examined in the regression models. RESULTS: Compared to Whites, African American mothers initiating childbearing at age 30 or older had significantly higher rates of adverse outcomes in the first and second pregnancy (P < 0.0001). Generally, African Americans had significantly higher rates of second pregnancy following intervals <6 months compared to Whites; however, no significant racial differences were noted in interpregnancy interval distribution pattern after controlling for maternal age at first pregnancy. African Americans delaying initiation of childbearing had significantly higher risk for adverse perinatal outcomes in the second pregnancy compared to Whites after controlling for potential confounders, however there were no significant interactions between maternal age at first pregnancy, race and short interpregnancy interval. CONCLUSION: Although African Americans were less likely to delay initiation of childbearing than were White women, their risk for adverse perinatal outcomes was much greater. As health care providers strive to address racial disparities in birth outcomes, there is need to pay attention to this unique group of women as their population continues to increase.

Pregnancy spacing among women delaying initiation of childbearing.

INTRODUCTION: An increasing proportion of women in the US and other countries delay initiation of childbearing until their thirties. Little is known about their subsequent pregnancies, particularly with regard to pregnancy spacing. OBJECTIVES: To determine interpregnancy interval (IPI) patterns, factors associated with IPI among women delaying initiation of childbearing until their thirties, and ascertain if delay in initiation of childbearing is associated with increased likelihood for short interpregnancy interval of less than 6 months. METHODS: A retrospective cohort study was performed using the Missouri maternal linked file for 1978-1997, inclusive. Analysis was limited to mothers aged 20-50 years at first pregnancy, having a first and second pregnancy during the study period; the sample size included 242,559 mother-infant pairs. Analysis strategies included stratified analysis, and multivariable logistic regression. Interpregnancy interval was main outcome variable, and was grouped in seven categories: 0-5, 6-11, 12-17, 18-23, 24-59, 60-119, >or=120 months. RESULTS: The mean interpregnancy interval was significantly shorter for women delaying start of childbearing (>or=30 years) compared to 20-29 year olds. Observed intervals are 31 (+/-24) months for mothers aged 20-29 years, 25 (+/-17) months for mothers aged 30-34 years, 21 (+/- 14) for 35-39 year olds, and 19 (+/-16) for 40-50 year olds (P < 0.0001). A significant trend for shorter intervals was noted as maternal age at first pregnancy increased (P < 0.0001). Factors associated with interpregnancy interval for women delaying initiation of childbearing included adverse outcome in preceding pregnancy, and low educational status. Mothers aged 35 and above at first pregnancy had increased odds for a second pregnancy following short IPI <6 months; (35-39 years OR = 1.26 95% CI 1.11-1.44; 40-50 OR = 1.91 95% CI 1.13-3.24). Mothers aged 30-34 years have lower odds for short IPI (OR = 0.93 95% CI 0.87-0.99). CONCLUSION: First time mothers aged 35 and above have higher odds of having a second pregnancy shortly after their first pregnancy. Given the increasing number of first time mothers aged 35 and above, these findings are of relevance for preconception counseling for this unique population of women.

First-time births among women 30 years and older in the United States: patterns and risk of adverse outcomes.

OBJECTIVE: To update the trends in initiation of childbirth by age of the mother, describing the characteristics of women having their first child at age 30 or above, and to determine the risk for adverse pregnancy outcomes for this group of women. STUDY DESIGN: This was a cross-sectional study using National Center for Health Statistics linked live birth and infant death cohort files from 1995 to 2000, and Natality file from 1980 to 2002. Analysis was limited to index pregnancies only. Logistic regression analysis was used to determine the risk of poor outcomes. RESULTS: There is a decreasing trend of first-time births to women 20-29 years old, while births to women 30 and older are showing a continued rise. As compared to 20-29-year-olds, women who start childbearing at age 30 or older are at increased risk of maternal complications in general. However, 30-34-year-olds have a reduced risk for pregnancy-induced hypertension and pre-existing hypertension. Infants born to women aged 30 and above are at increased risk for prematurity and low birth weight in addition to fetal and infant mortality. CONCLUSION: Because of the increasing trend of women starting childbearing in their 30s and the increased risk for poor outcomes in older women, health providers need to pay extra attention to this group of women as they plan and deliver services for them.

Creating a regional pediatric medical disaster preparedness network: imperative and issues.

Over the past few decades, the number of disasters, both natural and human initiated has increased. As a result, since the September 11, 2001 attacks on the World Trade Center and Pentagon, there has been a new emphasis on disaster preparedness. However, the preparedness emphasis has been primarily directed toward adults and little attention has been specifically given to the needs of children. One reason for the lack of attention to pediatric needs in disaster planning is that childhood is seldom viewed as a separate and special stage of growth, fundamentally different from adulthood. The expectation during emergencies is that the care provided for adults is appropriate for children. The purpose of this paper is to examine the types of and increase in disasters and discuss the importance of specifically addressing the special needs of children in disaster planning. Further the paper argues for a regional network approach to emergency pediatric care that would increase surge capacity for children during disasters and other emergencies.

Racial and ethnic differences in perinatal mortality: the role of fetal death.

PURPOSE: We investigate whether variations in infant mortality rates among racial/ethnic groups could be explained by variations in fetal mortality rates where relatively higher infant mortality rates may correspond to lower fetal mortality rates due to possible systematic differences in reporting of fetal death compared to live births. METHODS: Using US perinatal data from 1995 to 1999, we calculated crude mortality rates, birth weight-specific fetal and hebdomadal mortality rates, risks of perinatal death, and the risk of being classified as a fetal death versus other period death among infants born to Non-Hispanic White, Non-Hispanic Black, and Hispanic mothers. RESULTS: Two-fold disparities between Whites and Blacks persist for all mortality categories. Black low birth-weight deliveries, compared to Whites, have perinatal advantages in both fetal and hebdomadal periods. Hispanics were less likely than Whites to be reported as a fetal versus a hebdomadal death. CONCLUSIONS: While these data suggest some underreporting of Black fetal deaths, they provide little evidence that Black-White disparities in infant mortality are a function of variations in classifying a death occurring at delivery as either a fetal death or as a live birth-infant death. These data suggest that the lack of a White-Hispanic disparity in fetal mortality rates may be influenced by underreporting.

The association of child condition severity with family functioning and relationship with health care providers among children and youth with special health care needs in Alabama.

OBJECTIVE: The purpose of the present study is to assess how the severity of a child's condition affects family functioning and the relationship with health care providers among children with special health care needs in Alabama. METHODS: Using the data from the National Survey of Children with Special Health Care Needs (CSHCN), three variables were used as measures of condition severity: responses to the CSHCN screener questions, whether condition affected the ability to do things for children and youth with special health care needs (CYSHCN), and the level of severity of CYSHCN's condition. The dependent variables included family functioning and provider relationship. RESULTS: CYSHCN who only take prescription medicine for their chronic condition (MO) had lower condition severity from those who have other needs (NMO). In NMO CYSHCN, higher condition severity was associated with increased strain on family functioning outcomes and higher unmet needs in provider relationship outcomes, adjusted for demographic and insurance variables. Families of NMO CYSHCN with a more severe condition spent more temporal and financial resources and had a higher need for professional care coordination, and were less likely to have sensitive providers. CONCLUSIONS: Severity of condition is an important factor increasing strain on family resources and relationship with the provider. Our results indicate the need for professional care coordination and family support, particularly among those families in which there is a NMO CYSHCN with a more severe condition. This finding supports the mandate that all CYSHCN should have their health care coordinated and provided in the context of a medical home.