Exploring Trauma- and Violence-Informed Pregnancy Care for Karen Women of Refugee Background: A Community-Based Participatory Study.

Women of refugee background experience poorer perinatal outcomes when compared to their local-born counterparts. Women of refugee background have often experienced trauma and are likely to encounter barriers to accessing health services in host countries which can exacerbate their recovery from trauma and contribute to poor health outcomes. Trauma- and violence-informed approaches to care offer opportunities to address barriers to pregnancy care which may, in turn, improve these poor outcomes. Trauma- and violence-informed care is a framework that acknowledges a person's experiences of trauma, recognises its impact and symptoms, and works toward resisting re-traumatisation by integrating knowledge into practice. Despite this, trauma- and violence-informed care in maternity care settings has rarely been explored from the perspectives of women of refugee background. This study aimed to explore trauma- and violence-informed pregnancy care from the perspectives of Karen women of refugee background using Community-Based Participatory Research methods. The lead researcher is a Karen-Australian woman with lived refugee experience. A Community Advisory Group was formed to support the study. Semi-structured interviews were conducted with seven Karen women of refugee background who had recently had a baby in Western metropolitan Melbourne, Australia. The data were analysed using Reflexive Thematic Analysis. Karen women shared what they considered to be important elements of trauma- and violence-informed pregnancy care. Three major elements were identified: (1) care design and accessibility; (2) promoting choice and control; and (3) trauma-informed interpreting. The critical importance of the interpreter-mediated setting was highlighted as women reported that they may not experience trauma- and violence-informed maternity care if they cannot access an interpreter or their relationship with the interpreter is unsafe. This study offers critical insights regarding the elements of trauma- and violence-informed pregnancy care that are important to Karen women of refugee background.

'It is human work': qualitatively exploring community roles that facilitate cultural food security for people from refugee backgrounds.

OBJECTIVES: Cultural food security is crucial for cultural health and, for people from refugee backgrounds, supports the settlement journey. Cultural communities are vital in facilitating access to cultural foods; however, it is not understood how refugee-background communities sustain cultural food security in the Australian context. This study aimed to explore key roles in refugee-background communities to understand why they were important and how they facilitate cultural food security. DESIGN: Interviews were conducted by community researchers, and data analysis was undertaken using best-practice framework for collaborative data analysis. SETTING: Greater Brisbane, Australia. PARTICIPANTS: Six interviews were conducted between August and December 2022 with people from a refugee-background community, lived in Greater Brisbane and who fulfilled a key food role in the community that facilitated access to cultural foods. RESULTS: Fostering improved cultural food security supported settlement by creating connections across geographical locations and cultures and generated a sense of belonging that supported the settlement journey. Communities utilised communication methods that prioritised the knowledge, wisdom and experience of community members. It also provided community members with influence over their foodways. Community leaders had an ethos that reflected collectivist values, where community needs were important for their own health and well-being. CONCLUSIONS: Communities are inherently structured and communicate in a way that allows collective agency over foodways. This agency promotes cultural food security and is suggestive of increased food sovereignty. Researchers and public health workers should work with communities and recognise community strengths. Food security interventions should target cultural food security and autonomy.

The Importance of Local and Global Social Ties for the Mental Health and Well-Being of Recently Resettled Refugee-Background Women in Australia.

Social connections are foundational to the human condition and are inherently disrupted when people are forcibly displaced from their home countries. At a time of record high global forced migration, there is value in better understanding how refugee-background individuals engage theirsocial supports or ties in resettlement contexts. A mixed methods research design aimed to understand the complexities of how 104 refugee-background women experienced their social networks in the first few months of resettlement in Australia. One of the research activities involved participants completing a survey with both quantitative and qualitative components. The quantitative analyses identified the impact of post-migration living difficulties that represented social stressors (worry about family, loneliness and boredom, feeling isolated, and racial discrimination) on the women's mental health outcomes in the months following resettlement. The qualitative data highlighted the complexities of social relationships serving as both stressors and sources of support, and the importance of recognizing extended families and supports around the globe. The findings point to the need for nuanced accounts of the social contexts surrounding refugee resettlement as important influences able to promote trauma-informed and gender sensitive practices to support mental health and well-being in new settings.

Determinants of food security among people from refugee backgrounds resettled in high-income countries: A systematic review and thematic synthesis.

Food is intrinsically linked to culture, identity, and for people with lived refugee experiences, cultural foods are a critical part of settlement into a new country, which is often a time of high stress and dislocation from friends and family. However, cultural foods in settlement countries may be unavailable or inaccessible, adversely impacting on food security. This systematic review aimed to identify facilitators and barriers to accessing foods in high-income countries for people with lived refugee experiences. Sixteen health databases were searched from June 2020 and April 2021 and 22 articles met the inclusion criteria. Bias was assessed using a modified thematic synthesis method and the relevant Joanna Briggs Institute risk assessment checklist. Findings were thematically synthesised and the socio-ecological model and postcolonialism were used as a lens through which the data was viewed. Analysis revealed three themes: "Practicalities and Pragmatism"; "Identity, Belonging and Placemaking"; and "Postcolonial and Societal Influences". The determinants of food security were present across all levels of the socio-ecological model and people with lived refugee experiences used practical and pragmatic strategies to feed their families. Food was intrinsically linked to identity, belonging and placemaking, and as such, people preferred consuming cultural foods. Societies adversely affected the food security of people from refugee backgrounds by limiting their access to resources and restricting cultural food gathering practices, impacting on their ability to access or afford foods, especially cultural foods. To improve food security for people with lived refugee backgrounds, governments and organisations should collaborate with the cultural communities with lived experiences of accessing cultural foods, appreciate their strengths, and recognise the value of social and cultural capital.

Persistent psychological distress in resettled refugee women-at-risk at one-year follow-up: Contributions of trauma, post-migration problems, loss, and trust.

The mental health of women has been largely neglected in the refugee literature, notwithstanding the specific gender-related issues that confront women seeking asylum. Furthermore, a specific category of women, deemed to be women-at-risk, face particular challenges in their journey and resettlement process. This longitudinal study investigated psychological distress in refugee women-at-risk one year after resettlement in Australia. Follow-up survey of 83 women-at-risk (mean age = 33.41 years; SD = 11.93) assessed: trauma events and symptoms; loss events and loss distress; level of post-migration problems; anxiety, depression, and somatic symptoms; and absence of trust in community members. Participants demonstrated no symptom change since initial assessment (p > .05). Substantial proportions of women reported traumatization (39%), PTSD (20%), anxiety (32%), and depression (39%) above clinical cut-offs, and high levels of somatization and loss distress. Post-migration problems, trauma events, and region of birth were associated with all symptoms, with post-migration problems the strongest predictor. Absence of trust in community members was associated with trauma, depression, and somatic symptoms. Initial trauma and somatic symptoms were associated with follow-up traumatic and somatic symptoms. Loss and trauma events were associated with loss distress. Findings underline the role of post-migration problems on psychological distress and the need to consider women's psychological wellbeing in the context of their trauma and loss history, potential impacts of ethnicity, and complex socio-cultural dynamics underpinning issues of trust within communities. Effective service delivery requires that practitioners screen for and address psychological distress in women-at-risk at least up to 18 months after resettlement.

Climate change, food security and health in Kiribati: a narrative review of the literature.

BACKGROUND: Climate change is recognised as having a 'multiplier effect' on food insecurity and adverse health experiences of communities in the Pacific region. Islands are especially at risk due to their limited land availability, population pressures and, in the case of atolls, their low-lying topography making them vulnerable to sea level rise. AIM: This review examines the literature describing the relationship between climate change, food security and health in Kiribati. METHOD: A narrative review was conducted, looking at both peer-reviewed and non-peer-reviewed literature available online from 1 January 2008 to 14 August 2018, the search date. Sources from three databases of peer-reviewed literature, Google and additional sources from reference lists were included in the review. RESULTS: Thirty-seven items were included in this review. These show climate change is having a noticeable impact on food security and health in Kiribati. Four themes were identified from the literature that provide different perspectives to the problem outlined. CONCLUSION: Climate change is a pressing concern for the government of Kiribati and communities alike, and yet the problem is worsening, not improving. Further research is required to look at effective policies and cultural perspectives to address this problem.

Trauma Exposure and Mental Health Problems Among Adults in Central Vietnam: A Randomized Cross-Sectional Survey.

Background: There is relatively little evidence about the psychological and social impacts of trauma exposure in the general population in East Asian countries. Vietnam has a long history of war and poverty, is prone to natural disasters and has high mortality related to traffic accidents. The mental health systems may be inadequate to cope with the resultant trauma. Objectives: This research examines the lifetime prevalence of single and multiple traumas and the association between trauma exposure and depression, anxiety and post-traumatic stress disorder (PTSD) among a randomly selected sample of the adult population in Thua Thien-Hue province in central Vietnam. Methods: Six hundred and eight Vietnamese adults aged 18 years or older participated in the survey. The main tools in the face-to-face interview included the Life Event Checklist (LEC) to measure trauma exposure, the Hospital Anxiety and Depression Scale (HADS) and the PTSD Checklist for DSM-IV (PCL-IV). Hierarchical multiple logistic regression was used to examine associations between trauma exposure and mental health. Results: Forty seven percent of the participants experienced at least one traumatic event in their lifetime and about half of these people were exposed to multiple traumas. The prevalence of depression, anxiety, and PTSD symptoms among the total sample was 12.7, 15.5, and 6.9%, respectively. Prevalence of PTSD among those reporting trauma exposure was 14.8%. Exposure to a higher number of trauma types was associated with increased risk of having depression, anxiety, and PTSD symptoms. Interpersonal traumas were strongly associated with symptoms of all three mental disorders while non-interpersonal traumas were only associated with depressive symptoms. Conclusion: Our findings indicate high burden of lifetime trauma and mental ill health in the adult population of central Vietnam and show a cumulative effect of multiple traumas on symptoms of the three mental disorders. Interpersonal trauma appears to have a more harmful effect on mental health than non-interpersonal trauma. Efforts to improve mental health in Vietnam should focus on reducing risk of preventable interpersonal trauma in every stage of life, and more broadly, ensure greater availability of trauma-sensitive mental health programs and services.

Psychometric Properties of the Multidimensional Loss Scale with Refugee Women-at-Risk Recently Arrived in Australia.

Refugee women-at-risk represent a distinct and vulnerable refugee population. We investigated the psychometric properties of the Multidimensional Loss Scale (MLS) with 104 women-at-risk, recently-arrived in Australia. Cross-sectional survey included: the MLS (indexing loss events and loss distress); Harvard Trauma Questionnaire (Indexing Trauma Events and Trauma Symptoms), and; Hopkins Symptom Checklist-37 (indexing anxiety, depression, and somatization symptoms). Exploratory factor analyses of MLS loss distress revealed a six-factor model (loss of symbolic self; loss of home; loss of interdependence; loss of past aspirations; interpersonal loss, and; loss of intrapersonal integrity). Cronbach alphas indicated satisfactory internal consistency for loss events (0.83) and distress (0.88). Correlations supported convergent validity of loss distress with trauma symptoms (r = 0.41) and divergent validity with anxiety (r = 0.09), Depression (r = 0.29), and somatic (r = 0.24) symptoms. Findings support MLS use in assessment of loss and associated distress with refugee women-at-risk.

Recently resettled refugee women-at-risk in Australia evidence high levels of psychiatric symptoms: individual, trauma and post-migration factors predict outcomes.

BACKGROUND: Despite increasing numbers of refugee women-at-risk being resettled and their potential vulnerability, there exists no empirical research into the psychiatric health of this unique subgroup with which to guide policy and practice. This research aimed to investigate psychiatric symptom status of a sample of refugee women-at-risk recently resettled in Australia, as well as factors contributing to symptoms of trauma, anxiety, depression, and somatization. The level of psychiatric symptomatology is compared to reference groups of women from Sudan and Burma, who entered Australia under the Humanitarian Entry Programme, and who did not meet criteria as women-at-risk. METHODS: This is a cross-sectional survey of 104 refugee women-at-risk across several ethnic groups including a demographic questionnaire, the Harvard Trauma Questionnaire, Post-migration Living Difficulties Checklist, and Hopkins Symptom Checklist to assess individual factors, traumatic experiences, post-migration problems, and symptoms of trauma, anxiety, depression, and somatization. A series of multiple hierarchical regression analyses examined factors predicting psychiatric symptoms. RESULTS: Substantial proportions of participants reported psychiatric distress in symptomatic ranges, including for traumatization (41%), post-traumatic stress disorder (20%), anxiety (29%), and depression (41%), as well as significant symptoms of somatization (41%). These findings are significantly higher than those derived from reference groups of women from Sudan or Burma, resettled in the same area and utilizing a similar methodology. Higher numbers of trauma events and post-migration living difficulties predicted higher trauma, depression, and somatic (but not anxiety) symptoms. Having children predicted higher trauma, anxiety, and somatic symptoms. Greater English fluency predicted higher anxiety symptoms. Region of birth predicted anxiety and depression symptoms. Age predicted trauma and anxiety symptoms. CONCLUSIONS: Findings suggest that recently arrived refugee women-at-risk are at high risk of psychiatric disorders. The results indicate a need for comprehensive psychiatric assessment to identify women in need of treatment very early after resettlement, with implications for medical practice, service delivery, and policy programs.

Knowledge Adequacy on Cervical Cancer Among African Refugee and Non-Refugee Women in Brisbane, Australia.

Cervical cancer is a significant public health issue, especially in the developing countries of sub-Saharan Africa. To examine knowledge adequacy on cervical cancer and screening test among African refugee and non-refugee women in Brisbane and further examine whether the level of knowledge vary between refugee and non-refugee women. A cross-sectional survey was conducted among 254 African-born women conveniently sampled from the Brisbane local government area. The outcome measures were knowledge on cervical cancer and Pap smear. In the multivariate logistic regression analysis non-refugees were more likely than refugees to have adequate knowledge about cervical cancer. Also, non-refugee women who were older and educated beyond secondary school, were more likely to have good knowledge about Pap smear test than refugee women. Overall, knowledge level about cervical cancer is limited among the participants and non-refugee women were more likely than refugee women to have good knowledge about cervical cancer and the screening test. These findings may inform the development of health education interventions for the targeted population to improve knowledge and awareness about cervical cancer and the screening guidelines in Australia.

Barriers and facilitators of cervical cancer screening practices among African immigrant women living in Brisbane, Australia.

PURPOSE: To describe barriers and facilitators of cervical screening practices among African immigrant women living in Brisbane, Australia. METHOD: Nineteen African immigrant women (10 refugee and 9 non-refugee) were recruited using convenience sampling. The interviews were conducted with a semi-structured and open-ended questionnaire guide. All the interviews were audio recorded and transcribed verbatim. The data was manually analysed using interpretative thematic analysis. Thematic categories were identified and organised into coherent broader areas. RESULTS: Lack of knowledge about cervical cancer and Pap smear, the absence of warning signs, embarrassment, fear, concern about the gender of the service provider, lack of privacy, cultural and religious beliefs, and healthcare system factors were identified as barriers to screening. The results did not show any major differences between refugee and non-refugee women. Recommendation of the test by health professionals, provision of standardised information on the test, and preferences for female service providers were identified as facilitators of cervical screening. CONCLUSION: There is a need to provide culturally appropriate approaches to cervical screening practices and to enhance cultural competence among health professionals to apply service delivery models that honour group cultures.

A survey of cervical screening among refugee and non-refugee African immigrant women in Brisbane, Australia.

Issue addressed To compare the level of cervical screening uptake between refugee and non-refugee African immigrant women living in Brisbane, Australia, and examine factors associated with Pap smear testing. Methods Cross-sectional survey with a convenience sample of 254 women aged 21-62 years from 22 African countries (144 refugees, 110 non-refugees). Chi-square tests were used to compare the demographic and health-related characteristics between refugee and non-refugee women. Bivariate and multiple logistic regression analyses were used to assess the relationship between the outcome variable (Pap smear testing) and the independent variables. Results Two-thirds of women had used Pap smear services in Australia. Chi-square test analysis established that non-refugee women were significantly more likely to have used Pap smear services than refugee women (73.6% vs 61.8% respectively; P=0.047). Immigration status, however, was not a significant predictor of cervical screening uptake in the multiple regression analyses. The significant predictors for screening uptake in these analyses were work arrangement, parity, healthcare visit, knowledge about Pap smear and perceived susceptibility to cervical cancer. Conclusion Most women relied on opportunistic screening after receiving invitation letters to screen or after visiting health professionals for antenatal or postnatal care. So what? The findings suggest that organised cervical screening programs are not reaching most African immigrant women living in Brisbane. It is incumbent on the public health sector, including healthcare professionals and settlement agencies working with African communities, to develop health promotion strategies that meaningfully engage African immigrant women, including those from refugee backgrounds, to enhance their knowledge about cervical cancer and screening practices.

The persistence of predictors of wellbeing among refugee youth eight years after resettlement in Melbourne, Australia.

This short report assesses the predictors of subjective health and happiness among a cohort of refugee youth over their first eight years in Australia. Five waves of data collection were conducted between 2004 (n = 120) and 2012-13 (n = 51) using mixed methods. Previous schooling, self-esteem, moving house in the previous year, a supportive social environment, stronger ethnic identity and perceived discrimination were significant predictors of wellbeing after adjusting for demographic and pre-migration factors. When compared with a previous analysis of this cohort over their first three years of settlement, experiences of social exclusion still have a significant impact on wellbeing eight years after arriving in Australia. This study contributes to mounting evidence in support of policies that discourage discrimination and promote social inclusion and cultural diversity and which underpin the wellbeing of resettled refugee youth.

Women from refugee backgrounds and their experiences of attending a specialist antenatal clinic. Narratives from an Australian setting.

PROBLEM: In response to an identified need, a specialist antenatal clinic for women from refugee backgrounds was introduced in 2008, with an evaluation planned and completed in 2010. QUESTION: Can maternity care experiences for women from refugee backgrounds, attending a specialist antenatal clinic in a tertiary Australian public hospital, be improved? METHODS: The evaluation employed mixed methods, generating qualitative and quantitative data from two hospital databases, a chart audit, surveys and interviews with service users, providers and stakeholders. Contributions were received from 202 participants. FINDINGS: The clinic was highly regarded by all participants. Continuity of care throughout the antenatal period was particularly valued by newly arrived women as it afforded them security and support to negotiate an unfamiliar Western maternity system. Positive experiences decreased however; as women transitioned from the clinic to labour and postnatal wards where they reported that their traditional birthing and recuperative practices were often interrupted by the imposition of Western biomedical notions of appropriate care. The centrally located clinic was problematic, frequently requiring complex travel arrangements. Appointment schedules often impacted negatively on traditional spousal and family obligations. CONCLUSIONS: Providing comprehensive and culturally responsive maternity care for women from refugee backgrounds is achievable, however it is also resource intensive. The production of translated information which is high quality in terms of production and content, whilst also taking account of languages which are only rarely encountered, is problematic. Cultural competency programmes for staff, ideally online, require regular updating in light of new knowledge and changing political sensitivities.

Low vitamin B12 levels among newly-arrived refugees from Bhutan, Iran and Afghanistan: a multicentre Australian study.

BACKGROUND: Vitamin B12 deficiency is prevalent in many countries of origin of refugees. Using a threshold of 5% above which a prevalence of low Vitamin B12 is indicative of a population health problem, we hypothesised that Vitamin B12 deficiency exceeds this threshold among newly-arrived refugees resettling in Australia, and is higher among women due to their increased risk of food insecurity. This paper reports Vitamin B12 levels in a large cohort of newly arrived refugees in five Australian states and territories. METHODS: In a cross-sectional descriptive study, we collected Vitamin B12, folate and haematological indices on all refugees (n = 916; response rate 94% of eligible population) who had been in Australia for less than one year, and attended one of the collaborating health services between July 2010 and July 2011. RESULTS: 16.5% of participants had Vitamin B12 deficiency (<150 pmol/L). One-third of participants from Iran and Bhutan, and one-quarter of participants from Afghanistan had Vitamin B12 deficiency. Contrary to our hypothesis, low Vitamin B12 levels were more prevalent in males than females. A higher prevalence of low Vitamin B12 was also reported in older age groups in some countries. The sensitivity of macrocytosis in detecting Vitamin B12 deficiency was only 4.6%. CONCLUSION: Vitamin B12 deficiency is an important population health issue in newly-arrived refugees from many countries. All newly-arrived refugees should be tested for Vitamin B12 deficiency. Ongoing research should investigate causes, treatment, and ways to mitigate food insecurity, and the contribution of such measures to enhancing the health of the refugee communities.

Developing a best practice model of refugee maternity care.

BACKGROUND: About one third of refugee and humanitarian entrants to Australia are women age 12-44 years. Pregnant women from refugee backgrounds may have been exposed to a range of medical and psychosocial issues that can impact maternal, fetal and neonatal health. RESEARCH QUESTION: What are the key elements that characterise a best practice model of maternity care for women from refugee backgrounds? This paper outlines the findings of a project which aimed at developing such a model at a major maternity hospital in Brisbane, Australia. PARTICIPANTS AND METHODS: This multifaceted project included a literature review, consultations with key stakeholders, a chart audit of hospital use by African-born women in 2006 that included their obstetric outcomes, a survey of 23 African-born women who gave birth at the hospital in 2007-08, and a survey of 168 hospital staff members. RESULTS: The maternity chart audit identified complex medical and social histories among the women, including anaemia, female circumcision, hepatitis B, thrombocytopenia, and barriers to access antenatal care. The rates of caesarean sections and obstetric complications increased over time. Women and hospital staff surveys indicated the need for adequate interpreting services, education programs for women regarding antenatal and postnatal care, and professional development for health care staff to enhance cultural responsiveness. DISCUSSION AND CONCLUSIONS: The findings point towards the need for a model of refugee maternity care that comprises continuity of carer, quality interpreter services, educational strategies for both women and healthcare professionals, and the provision of psychosocial support to women from refugee backgrounds.

Health status and use of health services among recently arrived men with refugee backgrounds: a comparative analysis of urban and regional settlement in South-east Queensland.

Approximately one-third of refugee and humanitarian entrants to Australia are adult men. Many of these men and their families settle in regional areas. Little is known about the health status of refugee men and the use of health services, and whether or not there are differences between those living in urban and regional areas. This paper reports on the cross-sectional differences in health status and use of health services among a group of 233 recently arrived refugee men living in urban and regional areas of South-east Queensland. Overall, participants reported good levels of subjective health status, moderate to good levels of well-being, and low prevalence of mental illness. Men living in urban areas were more likely to have a long-standing illness and report poorer health status than those settled in regional areas. In contrast, men living in regional areas reported poorer levels of well-being in the environment domain and were more likely to visit hospital emergency departments. Targeted health promotion programs will ensure that refugee men remain healthy and develop their full potential as members of the Australian community. Programs that facilitate refugees' access to primary health care in regional areas may promote more appropriate use of hospital emergency departments by these communities.

Longing to belong: social inclusion and wellbeing among youth with refugee backgrounds in the first three years in Melbourne, Australia.

For young people with refugee backgrounds, establishing a sense of belonging to their family and community, and to their country of resettlement is essential for wellbeing. This paper describes the psychosocial factors associated with subjective health and wellbeing outcomes among a cohort of 97 refugee youth (aged 11-19) during their first three years in Melbourne, Australia. The findings reported here are drawn from the Good Starts Study, a longitudinal investigation of settlement and wellbeing among refugee youth conducted between 2004 and 2008. The overall aim of Good Starts was to identify the psychosocial factors that assist youth with refugee backgrounds in making a good start in their new country. A particular focus was on key transitions: from pre-arrival to Australia, from the language school to mainstream school, and from mainstream school to higher education or to the workforce. Good Starts used a mix of both method and theory from anthropology and social epidemiology. Using standardized measures of wellbeing and generalised estimating equations to model the predictors of wellbeing over time, this paper reports that key factors strongly associated with wellbeing outcomes are those that can be described as indicators of belonging - the most important being subjective social status in the broader Australian community, perceived discrimination and bullying. We argue that settlement specific policies and programs can ultimately be effective if embedded within a broader socially inclusive society - one that offers real opportunities for youth with refugee backgrounds to flourish.

Systematic review of the diagnostic accuracy of C-reactive protein to detect bacterial infection in nonhospitalized infants and children with fever.

OBJECTIVE: To determine the accuracy of C-reactive protein (CRP) for diagnosing serious bacterial and bacterial infections in infants and children presenting with fever. STUDY DESIGN: Systematic review of diagnostic accuracy studies. We included studies comparing the diagnostic accuracy of CRP with microbiologic confirmation of (a) serious bacterial and (b) bacterial infection. RESULTS: For differentiating between serious bacterial infection and benign or nonbacterial infection (6 studies), the pooled estimate of sensitivity was 0.77 (95% CI, 0.68, 0.83); specificity, 0.79 (95% CI, 0.74, 0.83); positive likelihood ratio, 3.64 (95% CI, 2.99, 4.43); and negative likelihood ratio, 0.29 (95% CI, 0.22, 0.40). In multivariate analysis, CRP is an independent predictor of serious bacterial infection. 3 studies investigating the accuracy of CRP for diagnosing bacterial infection could not be pooled, but all showed a lower sensitivity compared with studies using serious bacterial infection as the reference diagnosis. CONCLUSIONS: CRP provides moderate and independent information for both ruling in and ruling out serious bacterial infection in children with fever at first presentation. Poor sensitivity means that CRP cannot be used to exclude all bacterial infection.