Faculty Bibliography

PurposeTo estimate the effect of the culturally-adapted Greenlight intervention on parent activation and locus of control (LOC) among Chinese-American immigrant parents.DesignProspective, quasi-experimental study.SettingA New York City-based federally-qualified health center with a large patient population of low-income, ethnically Chinese immigrant individuals and families.Sample444 Immigrant Chinese-American parents of infants (267 cross-sectionally enrolled historical controls and 177 Greenlight recipients followed prospectively).InterventionA culturally-adapted version of Greenlight, a health literacy- and communication-informed early childhood obesity prevention intervention in primary care which promotes certain healthy infant feeding practices at 12 months in the present sample.MeasuresParent activation and LOC were measured at 6, 12, 24, and 36 month well child visits.AnalysisGeneralized estimating equations were used to examine the effects of the Greenlight intervention on the outcome measures.ResultsCompared to historical controls, parents receiving Greenlight were more likely to strongly agree with the activation statements: "I know how to prevent my child from becoming overweight" (adjusted odds ratio (aOR): 9.62 [4.70, 19.73]); "I have been able to help my child maintain recommended changes like eating right or exercising" (aOR: 6.42 [4.14, 9.97]); and "I am confident I can keep my child eating and exercising right, even when I am busy or stressed" (aOR: 8.44 [5.35, 13.31]). Greenlight recipients also demonstrated increased internal LOC (aOR: 2.02 [1.35, 3.03]) and decreased powerful others external LOC (aOR: 1.76 [1.23, 2.51]).ConclusionTo reduce disparities in child obesity, especially among immigrant families, interventions must also prioritize parent factors like parent activation and LOC to build upon their inherent assets and promote long-term change.

OBJECTIVE:Studies have demonstrated that using milliliters (mL)-only in dosing instructions and on dosing devices for oral liquid medications (OLMs) can prevent patient/caregiver dosing errors. While previous studies have assessed the perceptions/practices of primary care providers (PCPs) regarding dosing units for OLMs, perceptions/practices of community-based pharmacists are not well described. METHODS:Data were collected in June 2024, through an online survey of retail pharmacists. Pharmacist perceptions/practices regarding OLMs were calculated overall and stratified by the number of years practicing pharmacy. Logistic regression was used to assess associations between certain characteristics and perceptions on pharmacist dispensing behaviors. RESULTS:A total of 201 pharmacists completed the survey. Pharmacists who had been practicing for <10 years were more likely to think that mL-only was safest to use in dosing instructions for OLMs (88.9%) and that patients/caregivers prefer dosing instructions in mL-only (73.3%) compared to those who had been practicing for ≥10 years (70.5% and 37.2%, respectively). Only one-third (33.8%) of all pharmacists reported that they would convert the dosing units dispensed on a prescription for oral liquid amoxicillin to mL-only if the prescriber wrote the dosing instructions in teaspoons; with pharmacist perception that mL-only was the safest to use in dosing instructions having the most significant impact on this dispensing behavior (adjusted odds ratio 11.37, 95% confidence interval 3.20-40.44). CONCLUSIONS:Educational efforts promoting the importance of using mL-only units on dosing instructions/devices for OLMs for pharmacists and PCPs may be necessary to promote safe dosing practices and reduce pediatric medication errors.

OBJECTIVE:To examine whether disparities in preventable adverse events (AEs) and family experience for hospitalized children of parents with and without limited comfort with English (LCE) changed following implementation of a health literacy-informed, structured family-centered rounds intervention, Patient and Family Centered I-PASS. METHODS:Seven-center prospective before and after intervention study conducted from December 2014 to January 2017. Inclusion criteria includes parents and caregivers of hospitalized children less than 18 years old. LCE defined as parent and caregiver reporting any language other than English as the language in which they were most comfortable speaking to physicians and nurses. Preventable AE rates determined via (1) daily medical record surveillance, solicited clinician reports, hospital incident reports, and family safety interviews, followed by (2) dual-physician masked review and consensus rating. Changes assessed through multivariable mixed-effects logistic regression, controlling for complex chronic conditions, length of stay, parent race and ethnicity, education, and clustering by site. Family experience assessed via predischarge survey (6 domains, 5-point scale). Mixed-effects linear regression estimated changes in mean domain scores by language comfort. RESULTS:Of 1666 patients, 8.8% (n = 147) had parents with LCE. Preimplementation, over twice as many children of parents expressing LCE experienced preventable AEs, compared with children of parents expressing comfort with English (18.8% vs 7.6%; P = .001; adjusted odds ratio, 3.29; 95% CI, 1.48-7.31). Postimplementation, there were no significant differences between groups (6.4 vs 5.3%; P = .68; adjusted odds ratio, 1.26; 95% CI, 0.42-3.75). Some domains of family experience improved for both groups, although disparities in experience persisted in nurse communication. CONCLUSIONS:Patient safety disparities related to parental comfort with English narrowed after implementing a family-centered rounds communication intervention.

OBJECTIVE:Cross-sectional analyses have demonstrated an association between lower social capital and higher food insecurity in families with children. This study examined the association between social capital in the newborn period and household food insecurity at child age two years in a diverse US sample. METHODS:This secondary analysis used survey data from 596 child-caregiver dyads enrolled at six US academic sites in Greenlight Plus, a childhood obesity prevention trial. Proportional odds regression models analyzed associations between two newborn-period social capital measures, caregiver social support and neighborhood social cohesion, and household food insecurity at child age two years, adjusted for newborn-period food insecurity and sociodemographic covariates. Additional models evaluated the interaction between the two social capital exposures. RESULTS:In adjusted analyses, a low caregiver social support score of 18 was associated with over three times the odds of higher food insecurity at child age two years, compared to a high score of 30 (aOR=3.23 with 95%CI=1.84-5.68). Low neighborhood social cohesion in the newborn period was not significantly associated with higher household food insecurity at child age two years, with similar odds for a low neighborhood social cohesion score of 10 compared to a high score of 20 (aOR= 1.24 with 95%CI=0.56-2.78). Results remained similar when both social capital exposures were included in the same model, and no significant interaction was detected. CONCLUSIONS:Caregiver social support in the newborn period may represent a modifiable protective factor against developing or worsening household food insecurity in families with young children.

BACKGROUND:Best practices for engaging patients and the community in biomedical research evolved significantly in recent years. However, few focus on patient engagement in the design and implementation of a national study. OBJECTIVES/OBJECTIVE:To describe the initial engagement development and implementation; present findings from data collected during the first year; and discuss lessons learned. METHODS:Data were collected as part of continuous quality improvement efforts to assess and refine the engagement strategy. Fifty-two patient, caregiver, and community representatives were invited to complete a brief online survey about their experience participating in a national initiative. RESULTS:A framework for engagement was created and 35 representatives completed the survey (67% response rate). Representatives demonstrated awareness related to their roles and responsibilities. Seventy-six percent indicated that they felt comfortable expressing opinions and the decision-making process. CONCLUSIONS:The RECOVER initiative's approach promoted greater transparency and trust between researchers and the community, leading to more impactful engagement.

OBJECTIVE:To identify optimal strategies to integrate early relational health (ERH) programs in pediatric primary care (PPC) and to describe the development of a best practices toolkit to provide guidance and useful tools that clinicians can use to navigate this process. METHODS:A two-phased approach to develop, assess, and refine a best practices toolkit for the integration of multiple ERH programs in PPC through a modified Delphi process. Phase One included identification and assessment around barriers to ERH program integration and strategies to address them through surveys and focus groups of PPC clinics nationwide. Phase Two then utilized the identified barriers and strategies from Phase One to create a toolkit of best practices on integrating ERH programs in PPC that included two rounds of revision for a final version. RESULTS:126 PPC personnel from 44 clinics nationwide completed the Phase One survey, with respondents reporting many notable strengths and challenges to ERH program integration. 18 survey participants also participated in follow-up focus groups, which reiterated the strengths and challenges found in the surveys. An initial toolkit was then drafted, and experts provided qualitative, free-response feedback around clarity and presentation. Further improvement was made to create the final toolkit, which was rated highly useful and important, though slightly less feasible, by practitioners using formal feedback questions. CONCLUSION/CONCLUSIONS:This study employed a modified Delphi process to create a consensus-based best practices toolkit for integrating multiple ERH programs in PPC to help meet the heterogeneous needs of families to promote optimal child development.

BACKGROUND:Health literacy-informed and language-concordant written materials can promote caregiver understanding of care plans although are not commonly used in inpatient rounds. OBJECTIVES/OBJECTIVE:We sought to develop and evaluate a health literacy-informed, multilingual electronic real-time summary of rounds for hospitalized patients (the Rounds eSummary). METHODS:A multidisciplinary team developed the Rounds eSummary using health literacy, communication, and language equity best practices and multiple rounds of piloting. To generate the eSummary, clinicians completed a link with closed-ended options for various rounds components (e.g., illness severity, plan), caregiver's preferred language, and contact information. This generated an electronic PDF rounds summary (15 possible languages) emailed or texted to the family. We used descriptive statistics to analyze eSummaries (n = 437) created from October 25, 2024 to February 1, 2025. Separately, for a purposive sample of English eSummaries (n = 12) that represented different diagnoses and plans, two independent raters examined reading grade level (average of five formulas), understandability, and actionability (Patient Education Materials Assessment Tool for Printable Materials). RESULTS:Rounds eSummaries were generated in eight languages across three sites; the most common languages were English (89%), Spanish (6.2%), and Portuguese (1.8%). Plans commonly included medicines (42%), nutrition (30%), and oxygen (24%). More than half (61%) were accessed at least once by the patient/caregiver; of the eSummaries accessed, the average engagement time was 29.1 s (standard deviation 25.2). The average reading grade level was 6.8 (standard deviation 0.6, range 5.8-7.8). Overall understandability and actionability scores were 87% and 60%, respectively. CONCLUSION/CONCLUSIONS:We designed a usable Rounds eSummary that addressed language and health literacy barriers. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov identifier: NCT05591066.

BACKGROUND:A gap in the literature is the associations between longitudinal changes in food insecurity (FI) with parental feeding behaviors (PFB) and child weight status. METHODS:Secondary analysis of data from the Greenlight trial. Exposure was FI at 2 and 24 months, categorized as: no FI, food insecure to food secure (resolved FI), food secure to food insecure (new FI), or persistent FI. Outcomes included PFB, measured by the Child Feeding Questionnaire, and child weight outcomes. Adjusted linear models were used to estimate predicted means; pairwise comparisons were conducted with the no FI group as the referent group. RESULTS:= 0.07). CONCLUSIONS:Persistent food insecurity during the first 24 months of life were associated with differences in PFB that may contribute to obesity. CLINICAL TRIALS REGISTRATION/BACKGROUND:NCT01040897.

Health literacy and language impact comprehension of and adherence to written educational materials, including those for gastrostomy tubes (g-tubes). Our objective was to evaluate the readability, understandability, actionability, content, and language availability of a national sample of written g-tube educational materials. We conducted a cross-sectional study of g-tube educational materials from top 20 children's hospitals (US News and World Report) obtained via a systematic online search and provided by the institutions. We assessed material: (1) readability, (2) understandability and actionability (Patient Education Materials Assessment Tool for Printable Materials, (3) content, and (4) language availability. Mean (standard deviation [SD]) reading grade level was 8.3 (1.9). Mean (SD) understandability and actionability scores were 81.6% (12.1%) and 65.9% (23.2%), respectively. Materials covered a mean (SD) of 46.1% (25.3%) of content items; 20% of institutions provided materials in non-English languages. Future research should examine how to improve educational materials for children with g-tubes.

IMPORTANCE/UNASSIGNED:Millions of children worldwide are experiencing prolonged symptoms after SARS-CoV-2 infection, yet social risk factors for developing long COVID are largely unknown. As child health is influenced by the environment in which they live and interact, adverse social determinants of health (SDOH) may contribute to the development of pediatric long COVID. OBJECTIVE/UNASSIGNED:To identify whether adverse SDOH are associated with increased odds of long COVID in school-aged children and adolescents in the US. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional analysis of a multicenter, longitudinal, meta-cohort study encompassed 52 sites (health care and community settings) across the US. School-aged children (6-11 years; n = 903) and adolescents (12-17 years; n = 3681) with SARS-CoV-2 infection history were included. Those with an unknown date of first infection, history of multisystem inflammatory syndrome in children, or symptom surveys with less than 50% of questions completed were excluded. Participants were recruited via health care systems, long COVID clinics, fliers, websites, social media campaigns, radio, health fairs, community-based organizations, community health workers, and existing research cohorts from March 2022 to August 2024, and surveys were completed by caregivers between March 2022 and August 2024. EXPOSURE/UNASSIGNED:Twenty-four individual social determinant of health factors were grouped into 5 Healthy People 2030 domains: economic stability, social and community context, caregiver education access and quality, neighborhood and built environment, and health care access and quality. Latent classes were created within each domain and used in regression models. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Presence of long COVID using caregiver-reported, symptom-based, age-specific research indices. RESULTS/UNASSIGNED:The mean (SD) age among 4584 individuals included in this study was 14 (3) years, and 2330 (51%) of participants were male. The number of latent classes varied by domain; the reference group was the class with the least adversity. In unadjusted analyses, most classes in each domain were associated with higher odds of long COVID. After adjusting for many factors, including age group, sex, timing of infection, referral source, and other social determinant of health domains, economic instability characterized by difficulty covering expenses, poverty, receipt of government assistance, and food insecurity were associated with an increased risk of having long COVID (class 2 adjusted odds ratio [aOR], 1.57; 95% CI, 1.18-2.09; class 4 aOR, 2.39; 95% CI, 1.73-3.30); economic instability without food insecurity (class 3) was not (aOR, 0.93; 95% CI, 0.70-1.23). Poorer social and community context (eg, high levels of discrimination and low social support) was also associated with long COVID (aOR, 2.17; 95% CI, 1.77-2.66). Sensitivity analyses stratified by age group and adjusted for race and ethnicity did not alter or attenuate these results. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this study, economic instability that included food insecurity and poor social and community context were associated with greater odds of pediatric long COVID. Those with food security, despite experiencing other economic challenges, did not have greater odds of long COVID. Further study is needed to determine if addressing SDOH factors can decrease the rate of pediatric long COVID.