Adolescents' Receipt of Care in a Medical Home: Results From a National Survey.

PURPOSE: Despite long-term emphasis on the medical home for children, little research focuses on adolescents. This study examines adolescent past-year attainment of medical home, its components, and subgroup differences among demographic and mental/physical health condition categories. METHODS: Utilizing the 2020-21 National Survey of Children's Health (NSCH), ages 10-17 (N = 42,930), we determined medical home attainment and its 5 components and subgroup differences utilizing multivariable logistic regression: sex; race/ethnicity; income; caregiver education; insurance; language spoken at home; region; and health conditions: physical, mental, both, or none. RESULTS: Forty-five percent had a medical home with lower rates among those who were as follows: not White non-Hispanic; lower income; uninsured; in non-English-speaking households; adolescents whose caregivers lacked a college degree; and adolescents with mental health conditions (p range = .01-<.0001). Differences for medical home components were similar. DISCUSSION: Given low medical home rates, ongoing differences and high mental illness rates, efforts are needed to improve adolescent medical home access.

Physical health of care-experienced young children in high-income countries: a scoping review protocol.

INTRODUCTION: Care-experienced children have poorer health, developmental, and quality of life outcomes across the lifespan compared to children who are not in care. These inequities begin to manifest in the early years. The purpose of the proposed scoping review is to collate and synthesise studies of the physical health of young care-experienced children. The results of the review will help map the distribution of health outcomes, identify potential targets for intervention, and assess gaps in the literature relating to this group. METHODS AND ANALYSIS: We will carry out a scoping review of the literature to identify studies of physical health outcomes in care-experienced children. Systematic literature searches will be carried out on the MEDLINE, CINAHL and Web of Science Core Collection databases for items indexed on or before 31 August 2022. Studies will be included where the participants are aged 3 months or greater and less than 6 years. Data elements extracted from included studies will include study objectives, health outcomes, participant demographics, care setting characteristics and bibliographic information. The results of the review will be synthesised and reported using a critical narrative approach. Comparisons between care and non-care populations will be reported if sufficient studies are identified. ETHICS AND DISSEMINATION: Data will be extracted from publicly available sources, so no additional ethical approval is required. Results will be published in a peer-reviewed journal article. Furthermore, they will be shared in summary reports and presented to local authorities, care organisations and other relevant stakeholders that can influence healthcare policy and procedure relating to young children in care.

Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings.

Rationale: Pneumonia is the leading cause of death in children worldwide. Identifying and appropriately managing severe pneumonia in a timely manner improves outcomes. Little is known about the readiness of healthcare facilities to manage severe pediatric pneumonia in low-resource settings. Objectives: As part of the HAPIN (Household Air Pollution Intervention Network) trial, we sought to identify healthcare facilities that were adequately resourced to manage severe pediatric pneumonia in Jalapa, Guatemala (J-GUA); Puno, Peru (P-PER); Kayonza, Rwanda (K-RWA); and Tamil Nadu, India (T-IND). We conducted a facility-based survey of available infrastructure, staff, equipment, and medical consumables. Facilities were georeferenced, and a road network analysis was performed. Measurements and Main Results: Of the 350 healthcare facilities surveyed, 13% had adequate resources to manage severe pneumonia, 37% had pulse oximeters, and 44% had supplemental oxygen. Mean (±SD) travel time to an adequately resourced facility was 41 ± 19 minutes in J-GUA, 99 ± 64 minutes in P-PER, 40 ± 19 minutes in K-RWA, and 31 ± 19 minutes in T-IND. Expanding pulse oximetry coverage to all facilities reduced travel time by 44% in J-GUA, 29% in P-PER, 29% in K-RWA, and 11% in T-IND (all P < 0.001). Conclusions: Most healthcare facilities in low-resource settings of the HAPIN study area were inadequately resourced to care for severe pediatric pneumonia. Early identification of cases and timely referral is paramount. The provision of pulse oximeters to all health facilities may be an effective approach to identify cases earlier and refer them for care and in a timely manner.

Effect of a community-based child health counselling intervention on health-seeking behaviours, complementary feeding and nutritional condition among children aged 6-23 months in rural China: A pre- and post-comparison study.

In China, the prevalence of undernutrition among children under 5 years of age has declined significantly during recent decades. However, noticeable gaps exist between rural and urban areas. Since 2012, a government-funded nutrition programme, Ying Yang Bao (YYB; soybean powder-based iron-rich supplement) programme, has been implemented in poor rural areas to decrease the risk of developing anaemia among children aged 6-23 months, but there are still inadequate health care awareness, feeding knowledge and skills among caregivers. From June 2018 to December 2020, a child health counselling intervention was delivered through a home visit based on the YYB programme in Liangshan. Child health messages were given by trained village child health assistants while distributing YYB. Surveys were conducted before and after the intervention to analyse changes in child health check-up frequency, complementary feeding practice and prevalence of undernutrition. After the intervention, the proportion of children who had regular health check-ups, who were vaccinated and who met the minimum YYB consumption significantly increased from 26.0%, 81.6%, and 67.8% to 59.7%, 95.0%, and 79.2%. Increased rates of IYCF indicators (introduction of solid, semisolid, or soft foods, minimum dietary diversity and consumption of iron-rich or iron-fortified foods) were observed after the intervention. The prevalence of stunting, underweight, wasting, and anaemia significantly decreased from 26.3% to 10.8%, 13.4% to 8.7%, 14.0% to 10.5%, and 52.1% to 43.9%. This intervention can be well integrated into the YYB programme with less additional resources. Children in resource-limited areas will benefit more from a comprehensive nutritional package, including food supplements and child health education.

Trends in Health Care Use and Spending for Young Children With Neurologic Impairment.

BACKGROUND AND OBJECTIVES: Children with neurologic impairment (NI) are a growing subset of children who frequently use health care. We examined health care use and spending trends across services for children with NI during their first 5 years of life. METHODS: This was a retrospective study of 13 947 children with NI in the multistate IBM Medicaid MarketScan Database (2009-2017). We established birth cohorts of children with NI and analyzed claims from birth to 5 years. NI, identified by using International Classification of Diseases, 9th Revision, diagnosis codes, was defined as ≥1 neurologic diagnosis that was associated with functional and/or intellectual impairment. We measured annual health care use and per-member-per-year spending by inpatient, emergency department (ED), and outpatient services. Population trends in use and spending were assessed with logistic and linear regression, respectively. RESULTS: During their first versus fifth year, 66.8% vs 5.8% of children with NI used inpatient services, and 67.8% vs 44.4% used ED services. Annual use in both categories decreased over 0-5 years (inpatient odds ratio: 0.35, 95% confidence interval: 0.34 to 0.36; ED odds ratio: 0.78, 95% confidence interval: 0.77 to 0.79). The use of outpatient services (primary care, specialty care, home health) decreased gradually. Per-member-per-year spending on inpatient services remained the largest spending category: $83 352 (90.2% of annual spending) in the first year and $1944 (25.5%) in the fifth year. CONCLUSIONS: For children with early-onset NI from 0-5 years, use and spending on inpatient services decreased dramatically; ED and outpatient service use decreased more gradually. These findings may help systems, clinicians, and families optimize care by anticipating and adjusting for shifting use of health care services.

Repercusión de la pandemia COVID-19 en la actividad pediátrica en Atención Primaria / Impact of the COVID-19 pandemic on the pediatric activity in Primary Care

Introducción. La pandemia por COVID-19 ha supuesto un cambio en nuestras vidas y deseamos conocer su influencia en las consultas de pediatría en Atención Primaria. Pacientes y métodos. Estudio observacional retrospectivo de la actividad en un Centro de Salud urbano entre enero 2019 y marzo 2021. Se realiza aleatorización estratificada para elegir semana y día y se incluyen todos los pacientes. La información se extrae del programa Medora. Se recogen las variables: fecha de consulta, fecha de nacimiento, profesional, sexo, patología crónica, tipo y motivo de consulta, hospitalización reciente y afectación por COVID-19. Se realiza un análisis de regresión logística binaria y análisis de regresión de joinpoint. Resultados. La muestra es de 1.802 consultas. La tendencia de las tasas de consultas es estable de forma global y en la atención de enfermería, pero hay cambios estacionales en la atención de los pediatras. Durante la pandemia el tipo de consulta a la demanda/urgencia ha sido inferior que la programada (Odds Ratio = 0,19, IC al 95%: 0,1 a 0,3) y la atención telefónica/no presencial superior a la programada (Odds Ratio = 4,01: IC95% 2,3 a 6,95). El comportamiento de las consultas por tipo de patologías, consulta de revisión, vacunaciones o aspectos administrativos ha sido similar antes y durante la pandemia. Conclusión. El volumen de atenciones en nuestro Centro de Salud ha sido similar durante el periodo estudiado. La atención telefónica/no presencial ha sido cuatro veces superior a la consulta programada. Existen diferencias estacionales con descenso estival (AU)

Introduction. Our aim is to know the impact of the pandemic on pediatric activity in Primary Care.Patients and methods. Retrospective observational study of pediatric activity in an urban Health Center between January 2019 and March 2021. Stratified randomization is performed to choose the week and day. All patients are included. The information collected is extracted from the Medora program. Date of consultation, date of birth, professional, sex, chronic pathology, type and reason for consultation, recent hospitalization and involvement by COVID-19 are collected. Binary logistic regression analysis and regression analysis of joinpoint are performed.Results. The sample is made up of 1802 consultations. Trend in consultation rates is stable globally and in nursing care, but there are seasonal changes in pediatric care. During the pandemic, the demand/urgent consultation was lower than scheduled (Odds Ratio = 0.19, 95% CI 0.1 to 0.3) and telephone/non-face-to-face consultations were higher than scheduled (Odds Ratio = 4.01: 95% CI 2.3 to 6.95). The behavior of consultations by type of pathology, review consultation, vaccinations or administrative aspects has been similar before and during the pandemic.Conclusion. The number of consultations in our Health Center has been similar along the studied period. Telephone/non-face-to-face assistance has been four times higher thanscheduled consultation. There are seasonal differences in pediatric care with a summer decline (AU)

Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children's Hospitals.

Importance: Increasing hospital costs for bronchiolitis have been associated with increasing patient complexity and mechanical ventilation. However, the associations of illness severity and diagnostic coding practices with bronchiolitis hospitalization costs have not been examined. Objective: To investigate the association of patient complexity, illness severity, and diagnostic coding practices with bronchiolitis hospitalization costs. Design, Setting, and Participants: This retrospective cross-sectional study included 385 883 infants aged 24 months or younger who were hospitalized with bronchiolitis at 39 hospitals in the Pediatric Health Information System database from January 1, 2010, to December 31, 2019. Exposure: Hospitalization for bronchiolitis. Main Outcomes and Measures: Inflation-adjusted standardized unit cost (expressed in dollar units) per hospitalization over time. A nested subgroup analysis was performed to further examine factors associated with changes in cost. Results: A total of 385 883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227 309 of 385 883 boys (58.9%) and 253 870 of 385 883 publicly insured patients (65.8%). Among patients hospitalized with bronchiolitis, the median standardized unit cost per hospitalization increased significantly during the study period (from $5636 [95% CI, $5558-$5714] in 2010 to $6973 [95% CI, $6915-$7030] in 2019; P < .001 for trend). Similar increases in cost were observed among subgroups of patients without a complex chronic condition and without the need for mechanical ventilation. However, costs for patients without a complex chronic condition or mechanical ventilation, who received care outside the intensive care unit did not change in an economically significant manner (from $4803 [95% CI, $4752-$4853] in 2010 to $4853 [95% CI, $4811-$4895] in 2019; P < .001 for trend), suggesting that intensive care unit use was a primary factor associated with cost increases. Substantial changes in coding practices were observed. Among patients hospitalized with bronchiolitis, 1.2% (95% CI, 1.1%-1.3%) were assigned an APR-DRG (All Patient Refined Diagnosis Related Group) for respiratory failure in 2010, which increased to 21.6% (95% CI, 21.2%-21.9%) in 2019 (P < .001 for trend). Increased costs and coding intensity were not accompanied by objective evidence of worsening illness severity. Conclusions and Relevance: This cross-sectional study suggests that hospitalized children with bronchiolitis are receiving costlier and more intensive care without objective evidence of increasing severity of illness. Changes in coding practices may complicate efforts to study trends in the use of health care resources using administrative data.

Investment case approach for equitable access to maternal neonatal and child health services: Stakeholders' perspective in Nepal.

BACKGROUND: Investment Case is a participatory approach that has been used over the years for better strategic actions and planning in the health sector. Based on this approach, a District Investment Case (DIC) program was launched to improve maternal, neonatal and child health services in partnership with government, non-government sectors and UNICEF Nepal. In the meantime, this study aimed to explore perceptions and experiences of local stakeholders regarding health planning and budgeting and explore the role of the DIC program in ensuring equity in access to maternal and child health services. METHODS: This study adopted an exploratory phenomenography design with a purposive sampling technique for data collection. Three DIC implemented districts and three comparison districts were selected and total 30 key informant interviews with district level stakeholders and six focus groups with community stakeholders were carried out. A deductive approach was used to explore the perception of local stakeholders of health planning and budgeting of the health care expenses on the local level. RESULTS: Investment Case approach helped stakeholders in planning systematically based on evidence through collaborative and participatory approach while in comparison areas previous year plan was mainly primarily considered as reference. Resource constraints and geographical difficulty were key barriers in executing the desired plan in both intervention and comparison districts. Positive changes were observed in coverage of maternal and child health services in both groups. A few participants reported no difference due to the DIC program. The participants specified the improvement in access to information, access and utilization of health services by women. This has influenced the positive health care seeking behavior. CONCLUSIONS: The decentralized planning and management approach at the district level helps to ensure equity in access to maternal, newborn and child health care. However, quality evidence, inclusiveness, functional feedback and support system and local resource utilization should be the key consideration.

Factors affecting management of children's low-risk distal radius fractures in the emergency department: a population-based retrospective cohort study.

BACKGROUND: Ten randomized controlled trials over the last 2 decades support treating low-risk pediatric distal radius fractures with removable immobilization and without physician follow-up. We aimed to determine the proportion of these fractures being treated without physician follow-up and to determine whether different hospital and physician types are treating these injuries differently. METHODS: We conducted a retrospective population-based cohort study using ICES data. We included children aged 2-14 years (2-12 yr for girls and 2-14 yr for boys) with distal radius fractures having had no reduction or operation within a 6-week period, and who received treatment in Ontario emergency departments from 2003 to 2015. Proportions of patients receiving orthopedic, primary care and no follow-up were determined. Multivariable log-binomial regression was used to quantify associations between hospital and physician type and management. RESULTS: We analyzed 70 801 fractures. A total of 20.8% (n = 14 742) fractures were treated without physician follow-up, with the proportion of physician follow-up consistent across all years of the study. Treatment in a small hospital emergency department (risk ratio [RR] 1.86, 95% confidence interval [CI] 1.72-2.01), treatment by a pediatrician (RR 1.22, 95% CI 1.11-1.34) or treatment by a subspecialty pediatric emergency medicine-trained physician (RR 1.73, 95% CI 1.56-1.92) were most likely to result in no follow-up. INTERPRETATION: While small hospital emergency departments, pediatricians and pediatric emergency medicine specialists were most likely to manage low-risk distal radius fractures without follow-up, the majority of these fractures in Ontario were not managed according to the latest research evidence. Canadian guidelines are required to improve care of these fractures and to reduce the substantial overutilization of physician resources we observed.

Nursing consultations to children in primary health care: a feedback of researched data.

OBJECTIVE: To report the results of a dissertation developed with nurses who perform childcare consultations in Family Health Units in a Health District of João Pessoa, Paraíba, Brazil. METHODS: Experience report of the presentation and interpretation of the research results, in 2018, with 42 nurses, using the conversation strategy with two focus groups. RESULTS: The nurses showed disappointment with the negative results evidenced in the study's feedback, but they highlighted the importance of this moment for discussion and reflection of their practices, thus arousing the interest in qualifying the child's health care. FINAL CONSIDERATIONS: This study achieved the objective of promoting the dissemination of the findings of a research, coupled with the social and ethical commitment to return to the nurses and participating services with the feedback of the research results to improve the reality in which they work.

Reported Barriers to Healthcare Access and Service Disruptions Caused by COVID-19 in Burkina Faso, Ethiopia, and Nigeria: A Telephone Survey.

The coronavirus disease 2019 (COVID-19) pandemic may have short-term and long-term impacts on health services across sub-Saharan African countries. A telephone survey in Burkina Faso, Ethiopia, and Nigeria was conducted to assess the effects of the pandemic on healthcare services from the perspectives of healthcare providers (HCPs) and community members. A total of 900 HCPs (300 from each country) and 1,797 adult community members (approximately 600 from each country) participated in the study. Adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) were computed using modified Poisson regression. According to the HCPs, more than half (56%) of essential health services were affected. Child health services and HIV/surgical/other services had a slightly higher percentage of interruption (33%) compared with maternal health services (31%). A total of 21.8%, 19.3%, and 7.7% of the community members reported that their family members and themselves had difficulty accessing childcare services, maternal health, and other health services, respectively. Nurses had a lower risk of reporting high service interruptions than physicians (ARR, 0.85; 95% CI, 0.56-0.95). HCPs at private facilities (ARR, 0.71; 95% CI, 0.59-0.84) had a lower risk of reporting high service interruptions than those at governmental facilities. Health services in Nigeria were more likely to be interrupted than those in Burkina Faso (ARR, 1.38; 95% CI, 1.19-1.59). Health authorities should work with multiple stakeholders to ensure routine health services and identify novel and adaptive approaches to recover referral services, medical care, maternal and child health, family planning, immunization and health promotion, and prevention during the COVID-19 era.

Factors Influencing Sustained Utilization of Child Welfare Services among Children Aged 18 to 59 Months in a Low-Income Rural Community, Ghana.

BACKGROUND: Despite substantial progress in reducing child mortality, concerted efforts remain necessary to avoid preventable deaths in children under-5 years and to accelerate progress in improving child survival. The patronage of child welfare services is paramount to the attainment of these goals. This study identified the factors that influence the patronage of child welfare services in a rural community in the Ho West District of the Volta region. Methodology. This quantitative descriptive cross-sectional design employed a systematic sampling method to select 310 caregivers of children aged 18 to 59 months in the Abutia Kloe subdistrict using a pretested questionnaire. The data were entered into a Microsoft excel spreadsheet and cleaned and exported to Statistical Package for Social Sciences (SPSS 22) for analysis. RESULTS: The results showed that children (44.2%) had defaulted at a point during the continued growth monitoring process. The reasons for the default included completed major immunization (72.3%), started school (57.4%), and poor staff attitude (3.2%). Mothers have an idea about the purpose of the growth chart (68.0%) as the mothers (86.5%) are able to access a child welfare clinic in less than thirty minutes' walk from their homes. The cross tabulation on level of education and regular CWC attendance showed a strong association (r 2 = 8.071, p ≤ 0.03). Cross tabulation on marital status and CWC attendance showed a positive significant association (r 2 = 17.307, df = 2, p ≤ 0.001). Married caregivers (85.2%) as compared with unmarried ones (60.5%) are more likely to seek child welfare services for their child. CONCLUSION: Healthcare providers should intensify education on the need to continue growth monitoring up to 59 months even after the completion of major immunization. This goal can be attained if growth monitoring is incorporated into school health activities while policy implementers ensure the full execution.

Bronchiolitis and SARS-CoV-2.

BACKGROUND: It has been speculated that the SARS-CoV-2 was already widespread in western countries before February 2020. METHODS: We gauged this hypothesis by analysing the nasal swab of infants with either bronchiolitis or a non-infectious disease admitted to the Ospedale Maggiore, Milan (one of the first epicentres of SARS-CoV-2 outbreak in Europe) from November 2019. RESULTS: The SARS-CoV-2 RNA was never detected in 218 infants with bronchiolitis (95 females, median age 4.9 months) and 49 infants (22 females, median age 5.6 months) with a non-infectious disease between November 2019 and February 2020. On the contrary, two infants hospitalised for bronchiolitis between March and April 2020 tested positive for SARS-CoV-2. CONCLUSIONS: This study does not support the hypothesis that SARS-CoV-2 was already circulating among infants before the official outbreak of SARS-CoV-2 infection. However, it shows for the first time that SARS-CoV-2 might cause bronchiolitis requiring hospitalisation.

Health Services Use by Children in the Welfare System Who Died by Suicide.

OBJECTIVES: To examine characteristics and health service use patterns of suicide decedents with a history of child welfare system involvement to inform prevention strategies and reduce suicide in this vulnerable population. METHODS: A retrospective matched case-control design (120 suicide decedents and 1200 matched controls) was implemented. Suicide decedents included youth aged 5 to 21 who died by suicide and had an open case in Ohio's Statewide Automated Child Welfare Information System between 2010 and 2017. Controls were matched to suicide decedents on sex, race, and ethnicity. Comparisons were analyzed by using conditional logistic regressions to control for matching between the suicide and control groups. RESULTS: Youth in the child welfare system who died by suicide were significantly more likely to experience out-of-home placements and be diagnosed with mental and physical health conditions compared with controls. Suicide decedents were twice as likely to access mental health services in the 1 and 6 months before death, regardless of the health care setting. A significantly higher percentage of suicide decedents used physical health services 6 months before their death or index date. Emergency department visits for both physical and mental health conditions were significantly more likely to occur among suicide decedents. CONCLUSIONS: Suicide decedents involved in the child welfare system were more likely to use both mental and physical health care services in the months before their death or index date. Findings suggest that youth involved in the child welfare system may benefit from suicide prevention strategies in health care settings.

Receipt of Behavioral Health Services Among US Children and Youth With Adverse Childhood Experiences or Mental Health Symptoms.

Importance: Epidemiological literature on children's mental health and children's adverse childhood experiences (ACEs) have consistently pointed to widespread, unaddressed, and treatable high-risk conditions among children. Objective: To estimate the proportion of children with either high levels of ACEs and/or high levels of mental health symptoms who were not receiving services from behavioral health professionals. Design, Setting, and Participants: This cross-sectional study included 11 896 children who participated in 3 National Surveys of Children's Exposure to Violence (NatSCEV), which were nationally representative surveys conducted in 2008, 2011, and 2014. The surveys entailed telephone interviews with youth aged 10 to 17 years and caregivers of children aged 2 to 9 years. Data were analyzed from February to August 2020. Main Outcomes and Measures: Nationally representative samples were obtained from a mix of random digit dial and address-based sampling methods. The primary outcome was the proportion of children with high ACEs, high distress symptoms, and both who were receiving clinical contact, broken down by demographic characteristics. Results: Of the 11 896 children, 4045 (34.0%) participated in the 2008 NatSCEV; 4112 (34.6%) in the 2011 NatSCEV; and 3738 (31.4%) in the 2014 NatSCEV; 5532 (46.5%) were aged 2 to 9 years (2785 [50.4%] aged 2-5 years; 2693 [48.7%] girls; 3521 [63.7%] White children), and 6365 (53.5%) were aged 10 to 17 years (3612 [56.7%] aged 14-17 years; 3117 [49.0%] female participants; 4297 [67.5%] White individuals). Among participants aged 2 to 9 years, no clinical contact was reported for 57% (95% CI, 51%-62%) of the high ACE group, 53% (95% CI, 48%-58%) of the high distress symptom group, and 41% (95% CI, 32%-51%) of the group with high levels on both indicators. Among participants aged 10 to 17 years, the group with no clinical contact comprised 63% (95% CI, 56%-69%) of the high ACE group, 52% (95% CI, 46%-57%) of the high distress symptom group, and 62% (95% CI, 51%-71%) of youth scoring high on both indicators. Among racial groups, odds of contact were very low for Black children aged 2 to 9 years with high ACEs compared with non-Hispanic White children with the same age and exposure (odds ratio, 0.26; 95% CI, 0.14-0.49). Conclusions and Relevance: In this cross-sectional study combining findings from 3 US national surveys, large portions of children at high risk because of adversity or mental health symptoms were not receiving clinical services. Better ways are needed to find these at-risk populations and help them obtain relevant intervention resources.

Support for parents/carers of primary school aged gender diverse children in England, UK: a mixed-method analysis of experiences with health services.

This paper presents findings from a UK mixed-method study that aimed to understand parents/carers' views and experiences of support received from health services for primary school age (4-11) gender diverse children and their families. Data was collected via an e-survey including 10 open-ended questions with 75 parents/carers addressing experiences with (i) primary health services, including general practice (GP) clinics and child and adolescent mental health services (CAMHS) (ii) specialist gender identity development services (GIDS) (iii) non-health related support including transgender groups and online resources. Findings are organised into four themes: 'journey to health service provision', 'view on health services used', 'waiting' and 'isolation'. Discourses about gender diversity, childhood and the validity of trans healthcare shape parental experiences, including their desire for better information, more certainty in healthcare pathways and more expedient access to support services to reduce anxiety, distress and isolation. The emotional costs of waiting are compounded by the material costs of accessing the limited number of specialist services. Experiences could be improved through ensuring GPs and CAMHS are better prepared, expanding access to trans-specific support groups for those caring for children and young people, and exploring the provision of school-based support for gender diverse primary-age children.

The clinical workforce caring for emerging adults with diabetes in New Zealand is under resourced.

Diabetes is one of the most common chronic disorders in emerging adults (15-25 years of age), and the prevalence of both type 1 diabetes (T1D) and type 2 diabetes (T2D) in New Zealand continues to increase in this age group. Tight glycaemic control in both T1D and T2D is well known to reduce diabetic microvascular and macrovascular complications and improve survival. However, in New Zealand and worldwide, emerging adulthood is typically the period of worst glycaemic control in the lifespan due to the high prevalence of psychosocial stressors and increased insulin resistance of puberty and risk-taking behaviours. In addition, the glycaemic control of emerging adults with diabetes in New Zealand often deteriorates due to the loss of support from family and friends from moving regions, the failure of support from paediatric services to extend to emerging adulthood and the loss of public funding for insulin pump therapy as glycaemic targets are no longer met. Given the high prevalence of psychosocial stressors and the loss of support, the International Society for Paediatric and Adolescent Diabetes's (ISPAD's) guidelines recommend that emerging adults with diabetes receive ambulatory care from a dedicated multidisciplinary team consisting of 0.75 full time equivalent (FTE)/100 patients of an endocrinologist, 1-1.25 FTE/100 patients of a diabetes nurse specialist, 0.5 FTE/100 patients of a dietitian, 0.3 FTE/100 patients of a psychologist and 0.3 FTE/100 patients of a social worker or youth worker.

Heightened immigration enforcement impacts US citizens' birth outcomes: Evidence from early ICE interventions in North Carolina.

We examine how increased Immigration and Customs Enforcement (ICE) activities impacted newborn health and prenatal care utilization in North Carolina around the time Section 287(g) of the Immigration and Nationality Act was first being implemented within the state. Focusing on administrative data between 2004 and 2006, we conduct difference-in-differences and triple-difference case-control regression analysis. Pregnancies were classified by levels of potential exposure to immigration enforcement depending on parental nativity and educational attainment. Contrast groups were foreign-born parents residing in nonadopting counties and all US-born non-Hispanic parents. The introduction of the program was estimated to decrease birth weight by 58.54 grams (95% confidence interval [CI], -83.52 to -33.54) with effects likely following from reduced intrauterine growth. These results are shown to coexist with a worsening in the timing of initiation and frequency of prenatal care received. Since birth outcomes influence health, education, and earnings trajectories, our findings suggest that the uptick in ICE activities can have large socioeconomic costs over US-born citizens.

Reducing regional health inequality: a sub-national distributional cost-effectiveness analysis of community-based treatment of childhood pneumonia in Ethiopia.

BACKGROUND: Increasing the coverage of community-based treatment of childhood pneumonia (CCM) is part of the strategy to improve child survival, increase life-expectancy at birth and promote equity in Ethiopia. However, full coverage of CCM has not been reached in any regions of the country. There are no sub-national cost-effectiveness analyses available to inform decision makers on the most equitable scale up strategy. OBJECTIVES: Our first objective is to estimate the sub-national cost-effectiveness and the interindividual inequality impacts of scaling up CCM coverages to 90% in each region. Our second objective is to explore the costs, health effects, and geographical inequality impacts associated with three scale-up scenarios promoting different policy-aims: maximizing health, reducing geographical inequalities, and achieving 90% universal coverage. METHODS: We used Markov modelling to estimate the sub-national cost-effectiveness of CCM in each region. All data were collected through literature review and adjusted to the region-specific proportions of the rural population. Health effects were modeled as life years gained and under-five deaths averted. Interindividual and geographical inequality impacts were measured by the GINI index applied to health. In scenario analysis we explored three different scale-up strategies: 1) maximizing health by prioritizing the regions where the intervention was the most cost-effective, 2) reducing geographical inequalities by prioritizing the regions with high baseline under-five mortality rate (U5MR), and 3) universal upscaling to 90% coverage in all the regions. RESULTS: The regional incremental-cost effectiveness ratio (ICER) of scaling up the intervention coverage varied from 26 USD per life year gained in Addis to 199 USD per life year gained in the Southern Nations, Nationalities, and Peoples' region. Universal upscaling of CCM in all regions would cost about 1.3 billion USD and prevent about 90,000 under-five deaths. This is less than 15,000 USD per life saved and translates to an increase in life expectancy at birth of 1.6 years across Ethiopia. In scenario analysis, we found that prioritizing regions with high U5MR is effective in reducing geographical inequalities, although at the cost of fewer lives saved as compared to the health maximizing strategy. CONCLUSIONS: Our model results illustrate a trade-off between maximizing health and reducing health inequalities, two common policy-aims in low-income settings.