Publications by authors named "Annie Gjelsvik"

67 Publications

The Association between Exercise in the Last Trimester of Pregnancy and Low Infant Birthweight among Rhode Island Mothers, 2016-2018.

R I Med J (2013) 2021 Apr 1;104(3):62-64. Epub 2021 Apr 1.

Director of the Master of Public Health Program and Associate Professor of Epidemiology and Pediatrics at the Brown University School of Public Health.

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April 2021

Association Between Cancer Diagnosis and Mental Health Among RI Adults, 2018.

R I Med J (2013) 2021 Mar 1;104(2):76-79. Epub 2021 Mar 1.

Comprehensive Cancer Control Program Manager, Rhode Island Department of Health, Adjunct Faculty at Providence College.

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March 2021

Do Unmet Health Needs Drive Pediatric Emergency Department Utilization?: A Population-Based Assessment.

Pediatr Emerg Care 2020 Dec 14. Epub 2020 Dec 14.

From the *Division of Pediatric Emergency Medicine, Hasbro Children's Hospital, Warren Alpert Medical School of Brown University, Providence, RI †School of Public Health ‡Department of Epidemiology §Department of Health Services, Policy and Practice, Brown University, Providence, RI ∥Hassenfeld Child Health Innovation Institute, Providence, RI.

Objective: Lack of access to basic health services is thought to increase emergency department (ED) utilization. This study assessed the relationship between unmet health care needs and pediatric ED utilization in the United States.

Methods: The National Survey of Children's Health was used (2016-2017; n = 71,360). Parent/guardians reported number of ED visits and the presence of unmet health needs (medical, dental, mental health, vision, hearing, other) in the last 12 months. Associations were analyzed using multinomial logistic regression modeling and accounted for the weighting and complex survey design of the National Survey of Children's Health.

Results: Children with 2 or more unmet health needs had 3.72 times (95% confidence interval, 2.25-6.16) risk of ≥2 ED visits when compared with those with 0 unmet health needs. This risk became nonsignificant when adjusted for race, ethnicity, age, insurance, having asthma, current medication status, health description, number of preventative health visits, and place to go for preventative health (aRR, 1.77; 95% confidence interval, 0.96-3.27). The adjusted association was also nonsignificant for specific types of unmet needs. Race, insurance status, age 0 to 3 years, current medication status, having asthma, ≥2 preventative visits, and poorer health were associated with ≥2 ED visits.

Conclusions: Unmet health needs were not found to be a significant driving force for ED utilization. Other factors were found to be more strongly associated with it. Future studies to understand the perception, motives, and complex interaction of various factors leading to ED use in high-risk populations may optimize care for these children.
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http://dx.doi.org/10.1097/PEC.0000000000002319DOI Listing
December 2020

The Association between Adverse Childhood Experiences and Diabetes Status during Pregnancy among Women in Rhode Island, 2016-2018.

R I Med J (2013) 2020 Nov 2;103(9):52-55. Epub 2020 Nov 2.

Director of Developmental Behavioral Pediatrics, Hasbro Children's Hospital, and Professor of Pediatrics, Alpert Medical School of Brown University.

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November 2020

Childhood Obesity Is Associated with Poor Academic Skills and Coping Mechanisms.

J Pediatr 2021 01 5;228:278-284. Epub 2020 Sep 5.

Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Hasbro Children's Hospital, Rhode Island Hospital, Providence, RI; Department of Pediatrics, Warren Alpert Medical School of Brown University, Hasbro Children's Hospital, Rhode Island Hospital, Providence, RI; Brown University School of Public Health, Providence, RI; Hassenfeld Child Health Innovation Institute, Brown University, Providence, RI; Department of Health Services, Policy and Practice, Brown University, Providence, RI.

Objective: To assess the relationship between obesity and select childhood flourishing markers including academic skills and coping strategies.

Study Design: Cross-sectional study utilizing parental reported data for children aged 10-17 years (n = 22 914) from the 2016 National Survey of Children's Health. Multiple binary regressions assessed the association between body mass index-for-age and 5 school-related and behavioral childhood flourishing markers independently and combined, including completing homework, showing interest in learning, finishing tasks, staying calm when challenged, and caring about academics. Analyses were adjusted for age, sex, depression, sleep, digital media exposure, poverty, and parental education level.

Results: Only 28.9% of children with obesity were reported to have all 5 markers, compared with 38% with overweight, and 40.5% with normal body mass index. In an adjusted model, children with obesity had significantly decreased odds of demonstrating 4 of 5 markers: showing interest in learning (aOR, 0.78; 95% CI, 0.62-0.97), finishing tasks (aOR, 0.77; 95% CI, 0.63-0.94), staying calm when challenged (aOR, 0.73; 95% CI, 0.59-0.90), and caring about academics (aOR, 0.69; 95% CI, 0.55-0.86). Completing homework was not associated with obesity. Youth with obesity also had 23% decreased odds (aOR, 0.77; 95% CI, 0.61-0.98) of meeting the combined measure for flourishing markers.

Conclusions: Childhood obesity is associated with poor academic skills and coping strategies which may lead to worse individual and public health outcomes. Further studies are needed to create validated flourishing measures and identify interventions that promote healthy youth behavior and academic success.
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http://dx.doi.org/10.1016/j.jpeds.2020.09.004DOI Listing
January 2021

Sounding the Alarm on Sleep: A Negative Association Between Inadequate Sleep and Flourishing.

J Pediatr 2021 01 3;228:199-207.e3. Epub 2020 Sep 3.

Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI; School of Public Health, Brown University, Providence, RI; Hassenfeld Child Health Innovation Institute, Brown School of Public Health, Providence, RI; Department of Health Services, Policy and Practice, Brown School of Public Health, Providence, RI.

Objective: To assess the national prevalence of inadequate sleep among school-age children and its relationship with childhood flourishing.

Study Design: This cross-sectional study analyzed 49 050 parental responses from the 2016-2017 National Survey of Children's Health for school-age children. Inadequate sleep duration was defined as <9 hours for 6- to 12-year-olds and <8 hours for 13- to 17-year-olds on an average weeknight. Five markers of flourishing were examined individually and as a combined measure. Logistic regression was used with complex survey design and applied weights.

Results: Inadequate sleep was found in 36.4% of 6- to 12-year-olds and in 31.9% of 13- to 17-year-olds. Compared with children with adequate sleep, 6- to 12-year-olds with inadequate sleep had increased odds of not showing interest and curiosity in learning (aOR, 1.61; 95% CI, 1.34-1.94), not caring about doing well in school (aOR, 1.45; 95% CI, 1.23-1.71), not doing homework (aOR, 1.44; 95% CI, 1.24-1.68), and not finishing tasks (aOR, 1.18; 95% CI, 1.03-1.35). Children aged 13-17 years with inadequate sleep had increased odds of not doing homework (aOR, 1.36; 95% CI, 1.17-1.58), not staying calm and in control when challenged (aOR, 1.34; 95% CI, 1.16-1.54), not showing interest and curiosity in learning (aOR, 1.34; 95% CI, 1.14-1.58), not finishing tasks (aOR, 1.20; 95% CI, 1.03-1.40), and not demonstrating the combined flourishing measure (aOR, 1.35; 95% CI, 1.17-1.56).

Conclusions: Nationally representative data show that one-third of school-age children have inadequate sleep. Inadequate sleep is associated with decreased flourishing. These data will help inform sleep policies and optimize child development.
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http://dx.doi.org/10.1016/j.jpeds.2020.08.080DOI Listing
January 2021

Transfusion, mortality and hemoglobin level: Associations among emergency department patients in Kigali, Rwanda.

Afr J Emerg Med 2020 Jun 6;10(2):68-73. Epub 2020 Feb 6.

Department of Emergency Medicine, Brown University Alpert Medical School, Providence, USA.

Background: Studies from high-income countries (HIC) support restrictive blood transfusion thresholds in medical patients. In low- and middle-income countries (LMIC), the etiologies of anemia and baseline health states differ greatly; optimal transfusion thresholds are unknown. This study evaluated the association of packed red blood cell (PRBC) transfusion with mortality outcomes across hemoglobin levels amongst emergency center (EC) patients presenting with medical pathology in Kigali, Rwanda.

Methods: This retrospective cohort study was performed using a random sample of patients presenting to the EC at the University Teaching Hospital of Kigali. Patients ≥15 years of age, treated for medical emergencies during 2013-16, with EC hemoglobin measurements were included. The relationship between EC PRBC transfusion and patient mortality was evaluated using logistic regression, with stratified analyses performed at hemoglobin levels of 7 mg/dL and 5 mg/dL.

Results: Of 3609 cases sampled, 1116 met inclusion. The median age was 42 years (IQR 29, 60) and 45.2% were female. Transfusion occurred in 12.1% of patients. Hematologic (24.4%) and gastrointestinal pathologies (20.7%) were the primary diagnoses of those transfused. Proportional mortality was higher amongst those receiving transfusions, although not statistically significant (23.7% vs 17.0%, p = 0.06). No significant difference in adjusted odds of overall mortality by PRBC transfusion was found. In stratified analysis, patients receiving EC transfusions with a hemoglobin >5.0 mg/dL, had 2.21 times the odds of mortality (95% CI 1.51-3.21) as compared to those ≤5.0 mg/dL.

Conclusions: No association between PRBC transfusion and odds of mortality was observed amongst EC patients in this LMIC setting. An increased mortality association was found for patients receiving PRBC transfusions with an initial hemoglobin >5 mg/dL. Results suggest benefits from PRBC transfusion are limited as compared to HIC. Further research evaluating emergent transfusion thresholds for medical pathologies should be performed in LMICs to guide practice.
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http://dx.doi.org/10.1016/j.afjem.2020.01.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320208PMC
June 2020

Higher education associated with better national tetanus vaccination coverage: A population-based assessment.

Prev Med 2020 05 18;134:106063. Epub 2020 Mar 18.

Department of Emergency Medicine, Department of Pediatrics, Brown Medical School, Providence, RI, United States of America; Department of Health Services Policy and Practice, Brown University School of Public Health, Providence, RI, United States of America.

Vaccination coverage among United States (U.S.) adults for tetanus continues to be lower than the national goals. Education has demonstrated a positive impact on vaccination coverage. However, recently there have been outbreaks of vaccine preventable conditions in areas with high college completion rates. This study assessed the relationship between education and tetanus vaccination. Data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS), a self-reported annual survey for non-institutionalized adults in the US from the Centers for Disease Control, was analyzed in 2019. The outcome was up-to-date tetanus vaccination if received within the last 10 years. Education was categorized into 1) grade 11 or less, 2) grade 12/GED, 3) college 1-3 years, and 4) college 4 or more years. Bivariate analyses and multivariable logistic regression were conducted on the analytic sample (n = 417,473) using Stata 15, accounting for weighting and the complex survey design. In 2016, 59.9% of U.S. adults had up-to-date tetanus vaccination. Higher education level was associated with increased odds of up-to-date tetanus vaccination. The highest odds were for those with 4 or more years of college education [aOR = 1.31; 95% (CI: 1.26-1.35)]. Female sex, Black (non-Hispanic), unemployed, not being married, not having insurance or a personal health care provider, and above 45 years of age had lower odds of up-to-date tetanus vaccination. Targeted community specific vaccination education programs for those without tertiary education may help enhance the knowledge and thus the overall vaccination status in the U.S.
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http://dx.doi.org/10.1016/j.ypmed.2020.106063DOI Listing
May 2020

Children With ADHD Engage in Less Physical Activity.

J Atten Disord 2021 Jun 14;25(8):1187-1195. Epub 2019 Dec 14.

Brown University, Providence, RI, USA.

Children with ADHD should engage in physical activity, given its known role as a treatment adjunct. The main objective of this study is to assess the relationship between ADHD diagnosis and physical activity among children in the United States. This retrospective population-based cross-sectional study used data from the 2016 caregiver reported, National Survey of Children's Health (NSCH). In the adjusted binary model, children with an ADHD diagnosis had 21% lower odds of engaging in daily physical activity than their nondiagnosed counterparts. In the adjusted multinomial model, children with ADHD were increasingly unlikely to report additional days of physical activity as compared to those without a diagnosis. Given the known benefits of physical activity for those with ADHD, this study underscores the need for enhanced access to an important treatment adjunct for this population.
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http://dx.doi.org/10.1177/1087054719887789DOI Listing
June 2021

Assessing the Association Between Maternal Education and Access to Pediatric Specialty Care.

Clin Pediatr (Phila) 2019 12 22;58(14):1478-1483. Epub 2019 Sep 22.

Brown University, Providence, RI, USA.

. Timely access to pediatric specialty care continues to be a pervasive issue. We aimed to identify factors associated with unmet pediatric specialty care needs by assessing the association with maternal level of education. . A sample was extracted from the 2011-2012 National Survey of Children's Health, which identified a subset of patients with unmet specialty care needs. Logistic regression models determined the strength of association between our sample and maternal level of education. . An estimated 12.5% of US children had unmet specialty care needs. Independent of confounding variables, children with mothers educated at a level of high school or less were 41% more likely to have unmet specialty care needs compared to those with mothers who were educated at a level greater than high school. . Maternal level of education can be used as a risk factor to assess whether a child will have unmet specialty care needs.
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http://dx.doi.org/10.1177/0009922819875528DOI Listing
December 2019

Adolescent Access to Patient-Centered Medical Homes.

J Pediatr 2019 10 6;213:171-179. Epub 2019 Aug 6.

Hassenfeld Child Health Innovation Institute, Brown University, Providence, RI; Department of Pediatrics, Alpert Medical School, Brown University, Providence, RI; Department of Health Services, Policy, and Practice, Brown University, Providence, RI.

Objectives: To analyze the distribution of patient-centered medical homes (PCMHs) among US adolescents, and to examine whether disparities exist among subgroups.

Study Design: Data on adolescents ages 12-17 years (n = 34 601) from the 2011-2012 National Survey of Children's Health were used in this cross-sectional study to determine what proportion had access to a PCMH. Multivariable logistic regression was used to calculate the odds of having a PCMH, adjusting for sociodemographic characteristics and special health care needs. Comparisons were made to distribution of PCMH in 2007.

Results: Although most US adolescents had a usual source of care (91%), only about one-half (51%) had access to a PCMH. Disparities in the prevalence of PCMHs were seen by race/ethnicity, poverty, and having special health care needs. There were lower adjusted odds in having a PCMH for Hispanic (aOR, 0.56; 95% CI, 0.45-0.68) and black adolescents (aOR, 0.55; 95% CI, 0.46-0.66) compared with white adolescents. Those living below 4 times the poverty level had lower adjusted odds of PCMH access. Adolescents with 3-5 special health care needs had lower adjusted odds (aOR, 0.43; 95% CI, 0.35-0.52) of having a PCMH compared with adolescents without any special health care needs. Other than receiving family centered care, every component of PCMH was slightly lower in 2011-2012 compared with 2007.

Conclusions: PCMH access was lower among minorities, those living in poverty, and those with multiple special health care needs. These disparities in PCMH access among these typically underserved groups call for further study and interventions that would make PCMHs more accessible to all adolescents.
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http://dx.doi.org/10.1016/j.jpeds.2019.06.036DOI Listing
October 2019

Frequent Emergency Department Use by Children.

Pediatr Emerg Care 2019 Jul 11. Epub 2019 Jul 11.

Objectives: Frequent use of the emergency department (ED) is often targeted as a quality improvement metric. The objective of this study was to assess ED visit frequency by the demographic and health characteristics of children who visit the ED to better understand risk factors for high ED utilization.

Methods: The majority of pediatric ED services in Rhode Island are provided by a hospital network that includes the state's only children's hospital. Using 10 years of data (2005-2014) from this statewide hospital network, we examined ED use in this network for all children aged 0 to 17 years. Patients' home addresses were geocoded to assess their neighborhood characteristics.

Results: Between 2005 and 2014, 17,844 children visited 1 or more of the network EDs at least once. In their year of maximum use, 67.8% had only 1 ED visit, 20.1% had 2 visits, 6.9% had 3 visits, and 5.2% had 4 or more visits. In the adjusted multinomial logistic regression model, age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the ED were found to be significantly associated with increased visit frequency.

Conclusions: Risk factors for frequent ED use by children include age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the hospital. To decrease frequent pediatric ED use, improved medical management of complex medical problems is needed, but it is also essential to address modifiable social determinants of health care utilization in this population.
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http://dx.doi.org/10.1097/PEC.0000000000001859DOI Listing
July 2019

Adverse Childhood Experiences and Protective Factors With School Engagement.

Pediatrics 2019 08 8;144(2). Epub 2019 Jul 8.

Department of Pediatrics, Hasbro Children's Hospital, Providence, Rhode Island.

Objectives: To determine the associations of adverse childhood experiences (ACEs) and protective familial and community factors with school performance and attitudes in children ages 6 to 17.

Methods: A cross-sectional analysis of the 2011-2012 National Survey of Children's Health was performed. All data were demographically weighted and included 65 680 children ages 6 to 17. The survey identified up to 9 ACEs in each child. ACE scores were categorized as 0, 1, 2, 3, and ≥4 ACEs. Children's protective factors (PFs) included the following: safe neighborhood, supportive neighbors, 4 neighborhood amenities, well-kept neighborhood, no household smoking, ≥5 family meals per week, and a parent who can talk to the child. PFs were categorized into ≤3, 4, 5, 6, and 7 PFs. School outcomes included the following: child repeated ≥1 grade; never, rarely, or sometimes completes homework; and never, rarely, or sometimes cares about school. χ tests and logistic regressions assessed the relationships between ACEs and school outcomes, PFs and school outcomes, and both ACEs and PFs and school outcomes, adjusting for sex, age, race, ethnicity, and maternal education.

Results: Each negative school outcome is associated with higher ACE scores and lower PF scores. After adding PFs into the same model as ACEs, the negative outcomes are reduced. The strongest PF is a parent who can talk to the child about things that matter and share ideas.

Conclusions: As children's ACE scores increase, their school performance and attitudes decline. Conversely, as children's PF scores increase, school outcomes improve. Pediatric providers should consider screening for both ACEs and PFs to identify risks and strengths to guide treatment, referral, and advocacy.
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http://dx.doi.org/10.1542/peds.2018-2945DOI Listing
August 2019

Neighborhood Risk and Hospital Use for Pediatric Asthma, Rhode Island, 2005-2014.

Prev Chronic Dis 2019 05 30;16:E68. Epub 2019 May 30.

Hassenfeld Child Health Innovation Institute, Providence, Rhode Island.

Introduction: Studies consistently show that children living in poor neighborhoods have worse asthma outcomes. The objective of our study was to assess the association between negative neighborhood factors (ie, neighborhood risk) and pediatric asthma hospital use.

Methods: This retrospective study used data from children aged 2 to 17 years in a statewide (Rhode Island) hospital network administrative database linked to US Census Bureau data. We defined an asthma visit as an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code of 493 in any diagnosis field. We used 8 highly correlated measures for each census-block group to construct an index of neighborhood risk. We used maps and linear regression to assess the association of neighborhood risk with average annual census-block-group rates of asthma emergency department visits and hospitalizations. We used multivariable analyses to identify child characteristics and neighborhood risk associated with an asthma revisit, accounting for the child's sociodemographic information, season, and multiple measurements per child.

Results: From 2005 through 2014, we counted 359,195 visits for 146,889 children. Of these, 12,699 children (8.6%) had one or more asthma visits. Linear regression results showed 1.18 (95% confidence interval, 1.06-1.30) more average annual emergency departments visits per 100 children and 0.41 (95% confidence interval, 0.34-0.47) more average annual hospitalizations per 100 children in neighborhoods in the highest-risk index quintile than in neighborhoods in the lowest-risk index quintile.

Conclusion: Interventions to improve asthma outcomes among children should move beyond primary care or clinic settings and involve a careful evaluation of social context and environmental triggers.
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http://dx.doi.org/10.5888/pcd16.180490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549429PMC
May 2019

Intoxication and Flame Burn Injuries in Young Adults in the United States.

J Burn Care Res 2019 06;40(4):392-397

Hassenfeld Child Health Innovation Institute, Brown University, Providence.

Flame injuries are the primary cause of burns in young adults. Although drug and alcohol intoxication has been associated with other types of trauma, its role in burn injury has not been well described in this population. The purpose of this study was to investigate the association of intoxication and flame burn injuries in young adults in the United States. The 2014 Nationwide Emergency Department Sample was queried for burn injury visits of young adult patients, 13-25 years old. This data is weighted to allow for national estimates. Burn mechanism and intoxication status were determined by International Classification of Diseases, Ninth Revision codes. Multivariable logistic regression analysis was used to assess the association of intoxication and emergency department (ED) visits due to flame burns, adjusting for patient age, gender, zip code median income, zip code rural-urban designation, timing of visit, and hospital region. Further analyses assessed the odds of admission or transfer, as a possible proxy of injury severity, in patients with flame or other burns, with and without intoxication adjusting for patient age, gender, primary insurance, and hospital trauma designation. There were 20,787 visits for patients 13-25 years old with burn injuries and 12.9% (n = 2678) had a codiagnosis of intoxication. There was an increasing proportion of intoxication by age (5.8% 13-17 years old, 25% 18-20 years old, 69% 21-25 years old, P < .001). ED visits for burns with a codiagnosis of intoxication had 1.34 times ([95% confidence interval (CI): 1.18, 1.52], P < .01) higher odds of having flame burns compared to other burn mechanisms. Those with flame burns and intoxication were most likely to be admitted or transferred when compared to nonflame, nonintoxication visits in the adjusted model (odds ratio [OR] 5.49, [95% CI: 4.29, 7.02], P < .01). Furthermore, the odds of admission or transfer in visits with the combined exposure of intoxication and flame mechanism were significantly higher than visits due to nonflame burns and intoxication (OR 2.75, [2.25, 3.36], P < .01) or flame burns without intoxication (OR 3.00, [95% CI: 2.61, 3.42], P < .01). This study identified a significant association between flame-burn-related ED visits and intoxication in the young adult population in the United States. In addition, the combination of flame mechanism and intoxication appears to result in more substantial injury compared with either exposure alone. The relationship seen between intoxication and flame burn injury underscores a major target for burn prevention efforts in the young adult population.
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http://dx.doi.org/10.1093/jbcr/irz052DOI Listing
June 2019

The influence of depression status on weekly exercise in children ages 6 to 17 years.

Prev Med Rep 2019 Mar 11;13:199-204. Epub 2019 Jan 11.

Hassenfeld Child Health Innovation Institute, Brown University, Box G-S121-4, Providence, RI 02912, USA.

Exercise has been found to be an effective treatment for mild to moderate depression. The purpose of this study is to explore the relationship between depression status and weekly exercise in children ages 6 to 17 years stratifying by age and sex using a large nationally representative sample. The study data ( = 65,059) came from the 2011-12 National Survey of Children's Health. Depression categories were current, former, and no history of diagnosed depression. Exercise categories were exercising ≤6 days a week and 7 days a week. Multivariable regression stratified by age and by sex was conducted on the weighted survey data. Among children age 6 to 17, 95.2% were never depressed, 2.1% were formerly depressed, and 2.8% were currently depressed and 28.0% exercised daily. Currently depressed children had 0.75 (95% CI 0.56, 1.00) times and formerly depressed children had 1.09 (95% CI 0.76, 1.57) times the adjusted odds of exercising daily compared to never depressed children. Stratified separately by sex and by age, females and children age 12 to 17 with current depression had 0.63 (95% CI 0.42, 0.94) and 0.48 (95% CI 0.35, 0.66) times the adjusted odds of exercising daily compared to their counterparts with no depression. This study indicates a significant difference in daily exercise habits between currently depressed children age 12 to 17 and females compared to their never depressed counterparts. Healthcare workers should be aware of the possible heightened risk of physical inactivity for depressed female children and children age 12 to 17.
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http://dx.doi.org/10.1016/j.pmedr.2018.12.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6348765PMC
March 2019

Residential Mobility and Flourishing Among United States School-Age Children, 2011/2012 National Survey of Children's Health.

Matern Child Health J 2019 Apr;23(4):522-529

Hassenfeld Child Health Innovation Institute, Brown University School of Public Health, Providence, USA.

Objectives To investigate the association of residential mobility with flourishing among school-age children. Methods Data from the 2011/2012 National Survey of Children's Health were used to examine parent/caregiver-reported information on flourishing and residential mobility for children age 6-17 (N = 63,333). Residential mobility was the number of times the child moved categorized as: none, 1-2, and 3+. Children who were reported to show interest/curiosity, finish tasks, stay calm/in control, care about doing well in school, and do all homework were coded as flourishing. Sex-specific multivariable models were used to model the relative risk of mobility on flourishing. Interactions of mobility with age and poverty were tested. Results Among US school-age children, 22% had no moves, 39% had 1-2 moves and 39% had 3+ moves in their lifetime. Nearly half (45%) were flourishing. Both boys and girls who moved 3+ times were less likely to flourish compared to children with no moves. Among poor boys moving 3+ times was associated with less flourishing (aRR 0.83, 95% CI 0.71, 0.98) with no association for non-poor boy. Among girls the pattern was reversed (aRR 0.88, 95% CI 0.81, 0.95 for non-poor girls and no association for poor girls). Conclusions for Practice Residential mobility may lead to lower rates of flourishing. The patterns, when stratified by age or poverty, are different for boys and girls.
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http://dx.doi.org/10.1007/s10995-018-2664-1DOI Listing
April 2019

Depression among Women Released from Prison or Jail in the United States.

J Health Care Poor Underserved 2018 ;29(3):914-929

Risk factors for depression among 179 women recently released from prison or jail in a state correctional facility in the northeastern United States were examined in this study. The Center for Epidemiologic Studies Depression Scale (CESD-10) was used to measure longitudinal, self-reported depression data. In addition, potential risk factors for depression among women recently released from prison and jail were analyzed. Findings of this study indicated that approximately 83% of the women suffered depression throughout baseline and/or at least one follow up period after release. Significant risk factors for depression among these women included drug use, alcohol use, physical partner abuse, number of living children, and emotional abuse during childhood. Women who used drugs other than marijuana were eight times as likely to suffer from depression compared with women who had never used such drugs.
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http://dx.doi.org/10.1353/hpu.2018.0068DOI Listing
April 2019

Prenatal Exposure to Stressful Life Events and Infant Breastfeeding.

Breastfeed Med 2018 Jul/Aug;13(6):426-432. Epub 2018 Jul 9.

2 Department of Pediatrics, Warren Alpert Medical School of Brown University , Providence, Rhode Island.

Background: Of the various barriers to breastfeeding, limited information is available on the relationship between prenatal stress and breastfeeding. This study investigates the association between prenatal stressful life event (SLE) exposure and breastfeeding initiation postpartum.

Materials And Methods: Using Rhode Island Pregnancy Risk Assessment Monitoring System data from 2012 to 2014, SLE was defined as self-report of prenatal exposure to 14 predefined life events such as job loss or illness. Exposure to SLE was categorized by number and type of events. Multivariable logistic regression was performed to assess the relationship between SLE and breastfeeding initiation. Results accounted for complex survey design and were adjusted for maternal and infant characteristics (age, race, ethnicity, insurance, delivery type, parity, gestational age, birth weight for gestational age, and neonatal intensive care unit admission).

Results: Among 3,353 respondents, 86% reported breastfeeding initiation, 74% reported exposure to ≥1 SLE, and 17% reported exposure to ≥4 SLE. Decreased odds of breastfeeding initiation were associated with prenatal exposure to ≥4 SLE (adjusted odds ratio [aOR] 0.67; 95% confidence interval [CI]: 0.48-0.95), emotional stressors (aOR 0.77; 95% CI: 0.61-0.98), and traumatic stressors (aOR 0.68; 95% CI: 0.50-0.91).

Conclusion: This study underscores the impact of exposure to prenatal SLE on breastfeeding initiation among postpartum women. Findings may assist providers in identifying at-risk women for anticipatory guidance to improve breastfeeding rates.
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http://dx.doi.org/10.1089/bfm.2017.0200DOI Listing
April 2019

The Inverse Relationship between Digital Media Exposure and Childhood Flourishing.

J Pediatr 2018 06 15;197:268-274.e2. Epub 2018 Feb 15.

Departments of Emergency Medicine and Pediatrics, Hasbro Children's Hospital, Alpert Medical School of Brown University and Brown University School of Public Health, Providence, RI; Department of Health Services Policy and Practice, Brown University School of Public Health, Providence, RI.

Objective: To describe the relationship between digital media exposure (DME) and parental perception of childhood flourishing, or overall positive well-being. It is hypothesized that there is an inverse association between parent-reported measures of childhood flourishing and increasing daily DME.

Study Design: Parental responses for children ages 6-17 years (N = 64 464) from the 2011-2012 National Survey of Children's Health were analyzed. Average weekday DME that was not school work related was categorized in 2-hour intervals: 0 to <2, 2 to < 4, 4 to < 6, and ≥6 hours. Bivariate analyses and logistic regression models were used to examine the relationship between DME and parent-reported frequency of 5 childhood flourishing markers: completing homework, caring about academics, finishing tasks, staying calm when challenged, and showing interest in learning.

Results: Only 31% reported <2 hours of weekday DME. For the remaining children, daily DME was 2 to <4 hours (36%), 4 to <6 hours (17%), or ≥6 hours (17%). In a model adjusted for age, sex, race, poverty level, primary language spoken at home, and highest maternal education level, there was a dose-dependent decrease in the odds of demonstrating all 5 markers of flourishing as weekday DME increased (test for trend for each outcome P < .001). In stratified analyses, this relationship held true regardless of the child's age group, sex, or poverty level.

Conclusion: This study provides evidence that, among school-aged children, increasing weekday DME has an inverse dose-dependent relationship with multiple childhood flourishing markers.
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http://dx.doi.org/10.1016/j.jpeds.2017.12.016DOI Listing
June 2018

Having a Regular Primary Care Provider Is Associated With Improved Markers of Well-Being Among Children With Attention-Deficit Hyperactivity Disorder.

Clin Pediatr (Phila) 2018 08 30;57(9):1086-1091. Epub 2018 Jan 30.

2 Department of Epidemiology and Hassenfield Child Health Innovation Institute, Brown University, School of Public Health, Providence, RI, USA.

We examined the association between having a regular primary care physician (PCP) and measures of flourishing and academic success in children with attention-deficit hyperactivity disorder (ADHD). We performed a cross-sectional study using data from the 2011-2012 National Survey of Children's Health. Children aged 6 to 17 years with a diagnosis of ADHD were included in the study (n = 8173). The exposure was whether the guardian identified a regular PCP for their child. The outcomes were parental-reported measures of child well-being and academic performance. Among the study population, 8.9% reported no regular PCP. These children were found to be significantly less likely to finish assigned tasks (adjusted odds ratio [OR] = 0.52, 95% confidence interval [CI] = 0.35-0.79), care about school (adjusted OR = 0.62, 95% CI = 0.38-0.92), and finish homework (adjusted OR = 0.58, 95% CI = 0.36-0.88). There were no differences in other examined outcomes. Enhancing longitudinal care for this population may optimize their academic performance.
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http://dx.doi.org/10.1177/0009922818755119DOI Listing
August 2018

Prospective Association of Physical Activity and Heart Failure Hospitalizations Among Black Adults With Normal Ejection Fraction: The Jackson Heart Study.

J Am Heart Assoc 2017 Sep 7;6(9). Epub 2017 Sep 7.

Department of Family Medicine and Epidemiology, Alpert Medical School of Brown University Brown University School of Public Health, Providence, Rhode Island.

Background: Given high rates of obesity, hypertension, and diabetes mellitus, black persons are at risk to develop heart failure. The association of moderate to vigorous physical activity (MVPA) and heart failure in black adults is underresearched. The purpose of this study was to explore whether greater MVPA was associated with lower risk of heart failure hospitalizations (HFHs) among black adults with normal ejection fractions.

Methods And Results: We performed a prospective analysis of 4066 black adults who participated in the Jackson Heart Study and who had physical activity measured, had normal ejection fraction on 2-dimensional echocardiograms, and were followed for 7 years for incident HFH. We used Cox proportional regression analyses adjusted for age, sex, body mass index, smoking status, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, coronary heart disease, atrial fibrillation, and chronic kidney disease and examined effect modification by sex and body mass index. Of the eligible population, 1925 participants, according to the duration of MVPA, had poor health (0 minutes/week), 1332 had intermediate health (1-149 minutes/week), and 809 had ideal health (≥150 minutes/week). There were 168 incident HFHs. MVPA for intermediate and ideal health was associated with decreasing risk of incident HFH (hazard ratio: 0.70 [95% confidence interval, 49-1.00] and 0.35 [95% confidence interval, 0.19-0.64], respectively; =0.003). The full model revealed hazard ratios of 0.74 [95% confidence interval, 0.52-1.07] and 0.41 [95% confidence interval, 0.22-0.74], respectively. There was no effect modification between MVPA and body mass index or sex on incident HFH.

Conclusions: A dose-response relationship between increasing levels of MVPA and protection from incident HFH was found in black men and women with normal ejection fractions.
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http://dx.doi.org/10.1161/JAHA.117.006107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5634276PMC
September 2017

Pediatric Emergency Department Utilization and Reliance by Insurance Coverage in the United States.

Acad Emerg Med 2017 12 16;24(12):1483-1490. Epub 2017 Oct 16.

Hassenfeld Child Health Innovation Institute, Providence, RI.

Objectives: For many children, the emergency department (ED) serves as the main destination for health care, whether it be for emergent or nonurgent reasons. Through examination of repeat utilization and ED reliance (EDR), in addition to overall ED utilization, we can identify subpopulations dependent on the ED as their primary source of health care.

Methods: Nationally representative data from the 2010 to 2014 Medical Expenditure Panel Survey were used to examine the annual ED utilization of children age 0 to 17 years by insurance coverage. Overall utilization, repeat utilization (two or more ED visits), and EDR (percentage of all health care visits that occur in the ED) were examined using multivariate models, accounting for weighting and the complex survey design. High EDR was defined as having > 33% of outpatient visits in a year being ED visits.

Results: A total of 47,926 children were included in the study. Approximately 12% of children visited an ED within a 1-year period. A greater number of children with public insurance (15.2%) visited an ED at least once, compared to privately insured (10.1%) and uninsured (6.4%) children. Controlling for covariates, children with public insurance were more likely to visit the ED (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.40-1.73) than children with private insurance, whereas uninsured children were less likely (aOR = 0.64, 95% CI = 0.51-0.81). Children age 3 and under were significantly more likely to visit the ED than children age 15 to 17, whereas female children and Hispanic and non-Hispanic other race children were significantly less likely to visit the ED than male children and non-Hispanic white children. Among children with ED visits, 21% had two or more visits to the ED in a 1-year period. Children with public insurance were more likely to have two or more visits to the ED (aOR = 1.53, 95% CI = 1.19-1.98) than children with private insurance whereas there was no significant difference in repeat ED utilization for uninsured children. Publicly insured (aOR = 1.70, 95% CI = 1.47-1.97) and uninsured children (aOR = 1.90, 95% CI = 1.49-2.42) were more likely to be reliant on the ED than children with private insurance.

Conclusions: Health insurance coverage was associated with overall ED utilization, repeat ED utilization, and EDR. Demographic characteristics, including sex, age, income, and race/ethnicity were important predictors of ED utilization and reliance.
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http://dx.doi.org/10.1111/acem.13281DOI Listing
December 2017

Reply to: "Inaccuracies in SEER registry data on melanoma thickness".

J Am Acad Dermatol 2017 07;77(1):e19

Dermatoepidemiology Unit, Providence Veterans Affairs Medical Center, Providence, Rhode Island; Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island; Dermatology Department, The Warren Alpert Medical School, Brown University, Providence, Rhode Island.

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http://dx.doi.org/10.1016/j.jaad.2017.03.008DOI Listing
July 2017

The State of Prescreening Discussions About Prostate-specific Antigen Testing Following Implementation of the 2012 United States Preventive Services Task Force Statement.

Urology 2017 06 16;104:122-130. Epub 2017 Mar 16.

Minimally Invasive Urology Institute, Division of Urology, Brown University, Providence, RI.

Objective: To determine if the quality of prescreening discussions has changed following release of the United States Preventive Services Task Force statement against prostate cancer screening.

Methods: This cross-sectional study used the 2012 and 2014 Behavioral Risk Factor Surveillance System surveys. Respondents were categorized based on the year in which they responded to the Behavioral Risk Factor Surveillance System Survey. Quality of prescreening discussion was operationalized as having discussed only advantages, only disadvantages, both advantages and disadvantages, or neither. Race/ethnicity, education level, income, insurance status, and having a prostate-specific antigen (PSA) level actually drawn after prescreening counseling served as confounders in our multivariate analysis.

Results: Among 217,053 men in the analytic sample, 37% were told about only advantages of PSA screening compared to 30% of men who were advised about both advantages and disadvantages. Men who were told about neither advantages nor disadvantages were more likely to be Hispanic, not graduate high school, have low income, and not have insurance. Controlling for covariates, men in 2014 were significantly more likely to have undergone PSA testing without having discussed either advantages or disadvantages than men in 2012.

Conclusion: Comprehensive prescreening discussions about advantages and disadvantages of PSA testing are critical to informed decision making about prostate cancer screening. Disparities not only exist with regard to the quality of prescreening discussions that patients receive from their providers prior to PSA testing across categories of race/ethnicity, education, income, and insurance status, but these disparities became more substantial between 2012 and 2014. Further investigation is warranted to elicit more specific reasons behind these variations.
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http://dx.doi.org/10.1016/j.urology.2016.12.069DOI Listing
June 2017

Association of Sickle Cell Trait With Hemoglobin A1c in African Americans.

JAMA 2017 02;317(5):507-515

Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island13Center for Innovation in Long-Term Services and Support, Providence Veterans Affairs Medical Center, Providence, Rhode Island14Division of Cardiology, Providence Veterans Affairs Medical Center, Providence, Rhode Island15Department of Medicine, Alpert Medical School, Brown University, Providence, Rhode Island.

Importance: Hemoglobin A1c (HbA1c) reflects past glucose concentrations, but this relationship may differ between those with sickle cell trait (SCT) and those without it.

Objective: To evaluate the association between SCT and HbA1c for given levels of fasting or 2-hour glucose levels among African Americans.

Design, Setting, And Participants: Retrospective cohort study using data collected from 7938 participants in 2 community-based cohorts, the Coronary Artery Risk Development in Young Adults (CARDIA) study and the Jackson Heart Study (JHS). From the CARDIA study, 2637 patients contributed a maximum of 2 visits (2005-2011); from the JHS, 5301 participants contributed a maximum of 3 visits (2000-2013). All visits were scheduled at approximately 5-year intervals. Participants without SCT data, those without any concurrent HbA1c and glucose measurements, and those with hemoglobin variants HbSS, HbCC, or HbAC were excluded. Analysis of the primary outcome was conducted using generalized estimating equations (GEE) to examine the association of SCT with HbA1c levels, controlling for fasting or 2-hour glucose measures.

Exposures: Presence of SCT.

Main Outcomes And Measures: Hemoglobin A1c stratified by the presence or absence of SCT was the primary outcome measure.

Results: The analytic sample included 4620 participants (mean age, 52.3 [SD, 11.8] years; 2835 women [61.3%]; 367 [7.9%] with SCT) with 9062 concurrent measures of fasting glucose and HbA1c levels. In unadjusted GEE analyses, for a given fasting glucose, HbA1c values were statistically significantly lower in those with (5.72%) vs those without (6.01%) SCT (mean HbA1c difference, -0.29%; 95% CI, -0.35% to -0.23%). Findings were similar in models adjusted for key risk factors and in analyses using 2001 concurrent measures of 2-hour glucose and HbA1c concentration for those with SCT (mean, 5.35%) vs those without SCT (mean, 5.65%) for a mean HbA1c difference of -0.30% (95% CI, -0.39% to -0.21%). The HbA1c difference by SCT was greater at higher fasting (P = .02 for interaction) and 2-hour (P = .03) glucose concentrations. The prevalence of prediabetes and diabetes was statistically significantly lower among participants with SCT when defined using HbA1c values (29.2% vs 48.6% for prediabetes and 3.8% vs 7.3% for diabetes in 572 observations from participants with SCT and 6877 observations from participants without SCT; P<.001 for both comparisons).

Conclusions And Relevance: Among African Americans from 2 large, well-established cohorts, participants with SCT had lower levels of HbA1c at any given concentration of fasting or 2-hour glucose compared with participants without SCT. These findings suggest that HbA1c may systematically underestimate past glycemia in black patients with SCT and may require further evaluation.
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http://dx.doi.org/10.1001/jama.2016.21035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5713881PMC
February 2017

Mortality burden and prognosis of thin melanomas overall and by subcategory of thickness, SEER registry data, 1992-2013.

J Am Acad Dermatol 2017 Feb 22;76(2):258-263. Epub 2016 Nov 22.

Dermatoepidemiology Unit, Providence Veterans Affairs Medical Center, Providence, Rhode Island; Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island; Dermatology Department, The Warren Alpert Medical School, Brown University, Providence, Rhode Island.

Background: Thin melanomas cause a high death toll despite excellent prognosis.

Objective: We examined melanoma mortality burden and prognosis by categories of thickness within Surveillance, Epidemiology, and End Results (SEER) 13 Registry 1992-2013.

Methods: We divided 49,319 stage I and II melanoma cases diagnosed between 1992 and 2003 into T1 through T4 and then subdivided T1 into 0.01-0.25 mm, 0.26-0.50 mm, 0.51-0.75 mm, and 0.76-1.00 mm categories. We determined the number and proportion of deaths due to melanoma within 10 years of diagnosis for each thickness category and proportions within T1 subcategories with ulceration.

Results: We confirmed prognosis worsened as melanoma thickened from T1 to T4; however, most deaths resulted from melanomas that were diagnosed at the T1 stage. The smallest number of deaths within T1 resulted from 0.01-0.25 mm-thick melanomas; however, the risk for death within 10 years was greater for those diagnosed with melanoma when tumor depth was 0.01-0.25 mm than for those diagnosed when tumor depth was 0.26-0.50 mm. Prognosis worsened with depths starting at 0.51 mm. The pattern within T1 was not explained by ulceration.

Limitations: We did not evaluate melanoma subtype, mitotic rate, or other associated features.

Conclusion: Thin melanomas are a substantial public health burden. Efforts should be made to diagnose melanoma at the in situ stage.
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http://dx.doi.org/10.1016/j.jaad.2016.10.018DOI Listing
February 2017

Residential Proximity to Traffic-Related Pollution and Atherosclerosis in 4 Vascular Beds Among African-American Adults: Results From the Jackson Heart Study.

Am J Epidemiol 2016 11;184(10):732-743

To our knowledge, no study has investigated the association of long-term exposure to traffic pollution with markers of atherosclerosis in 4 vascular beds simultaneously in an all-African-American cohort. Among participants in the Jackson Heart Study (Jackson, Mississippi; baseline mean age = 55.5 (standard deviation, 12.7) years), we used linear regression to estimate percent differences in carotid intima-media thickness (CIMT) at baseline (2004) and used modified Poisson regression (robust error variance) to estimate prevalence ratios for peripheral artery disease (PAD), coronary artery calcification (CAC), and abdominal aortic calcification (AAC) at the first follow-up visit (2005-2008) for persons living less than 150 m (versus more than 300 m) from major roadways, adjusting for confounders. Living less than 150 m from such roadways was associated with a significant 6.67% (95% confidence interval: 1.28, 12.35) increase in CIMT (4,800 participants). PAD prevalence among persons living less than 150 m from a major roadway was 1.17 (95% confidence interval: 0.73, 1.86) times that of persons living more than 300 m away (4,443 participants), but this result was not statistically significant. There was no association for CAC or AAC. The association with CIMT was stronger in participants with a cardiovascular disease history than in those without one (P = 0.04). We observed an association in the carotid vascular beds but not the coronary, abdominal, or peripheral vascular beds. Our results highlight the need to consider residential proximity to roadways as a potential cardiovascular disease risk factor for blacks.
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http://dx.doi.org/10.1093/aje/kww080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5141947PMC
November 2016

Condom use and incarceration among STI clinic attendees in the Deep South.

BMC Public Health 2016 09 13;16:971. Epub 2016 Sep 13.

Institute for Community Health Promotion, School of Public Health, Brown University, Providence, RI, USA.

Background: Incarceration history is associated with lower rates of condom use and increased HIV risk. Less is known about duration of incarceration and multiple incarcerations' impact on condom use post-release.

Methods: In the current study, we surveyed 1,416 adults in Mississippi about their incarceration history and sexual risk behaviors. Generalized estimating equations (GEE) were used to test associations between duration of incarceration, multiple incarcerations, socio-demographic factors, substance use, sexual behavior, and event level condom use at last sex.

Results: After adjusting for covariates, having been incarcerated for at least 6 months two or more times remained significantly associated with condomless sex.

Conclusions: This study found a strong, independent relationship between condom use and multiple, long-term incarceration events among patients in an urban STI clinic in the Deep South. The results suggest that duration of incarceration and multiple incarcerations have significant effects on sexual risk behaviors, underscoring the deleterious impact of long prison or jail sentences on population health. Our findings also suggest that correctional health care professionals and post-release providers might consider offering comprehensive sexual and reproductive health services and those providing community care should consider screening for previous incarceration as a marker of risk.
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http://dx.doi.org/10.1186/s12889-016-3590-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5022228PMC
September 2016

The Association of Parental Coping and Childhood Injury.

Matern Child Health J 2016 11;20(11):2357-2366

Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University, Hasbro Children's Hospital, 55 Claverick Street, Providence, RI, USA.

Objectives Injuries are the leading cause of pediatric morbidity and mortality in the United States. Interaction between child, parent and environmental factors may contribute to injuries. This study investigates the association between coping with parenthood and injuries in children age 0-5 years. Methods In this cross-sectional observational study, we analyzed data from the 2007 National Survey of Children's Health, a random-digit-dialing, nationally-representative telephone survey. Information was obtained from a caregiver about children 5 years of age or younger. Parental coping with the demands of parenthood was categorized into three groups-"very well", "somewhat well" and "not very well" or "not very well at all". Injury was defined as caregiver report of any injury within the previous 12 months that required medical attention. Results This study included 27,471 surveys about children 5 years of age or younger. With weighted analysis, 10.4 % of children were reported to have an injury; 31.1 % of caregivers reported coping with parenthood "somewhat well" and 1.7 % reported coping "not very well"/"not very well at all". The adjusted odds ratio of sustaining an injury was 1.26 (95 % CI 1.00, 1.59) for children of parents who reported coping somewhat well with the demands of parenthood compared to those with parents coping very well. Conclusions Parental report of coping with parenthood less than very well was associated with injury in children ages 0-5 years, further highlighting the importance of the interaction between parent factors and childhood injury.
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http://dx.doi.org/10.1007/s10995-016-2059-0DOI Listing
November 2016