Children In Counties Research Articles

A parenting program delivered through existing community-based peer groups to improve early child development in Homabay and Busia Counties, Kenya: study protocol for a cluster-randomized controlled trial

BackgroundPoor early childhood development (ECD) is a major global health concern that is associated with various adverse outcomes over the lifecourse. Parenting interventions especially during the earliest years of life can benefit ECD. However, there is limited evidence from Kenya about the effectiveness of parenting interventions for improving ECD outcomes especially across rural disadvantaged communities. This paper describes the study protocol for an impact and implementation evaluation of a community-based group parenting program that aims to improve ECD in rural Kenya.MethodsWe will conduct a cluster-randomized controlled trial to determine the effectiveness of a parenting program for caregivers of young children in Homabay and Busia counties in Western Kenya. Sixty-four village clusters will be randomly assigned to either the parenting intervention arm or the waitlist control arm with stratification by county. In each village, 10 primary caregivers with a child aged 0–24 months will be enrolled. The parenting program will be delivered through existing peer groups within communities whereby caregivers will receive counseling and psychosocial support to enhance their parenting skills and wellbeing to in turn promote ECD. The intervention curriculum comprises 21 sessions targeting various nurturing care messages, including early learning, responsive caregiving, child nutrition, health, protection, and caregiver mental health. Group sessions are facilitated by a trained volunteer biweekly for a total of 11 months. The primary trial outcome is an overall measure of ECD using the Global Scales of Early Development long form version. Secondary outcomes include various caregiver outcomes (e.g., parenting practices, mental health) and other child outcomes (e.g., socioemotional development, dietary diversity). All outcomes will be assessed at baseline and endline. We will also conduct a qualitative implementation evaluation at endline and interview various stakeholders to assess program fidelity, quality, and sustainability.DiscussionThis trial will evaluate the effectiveness of a parenting intervention on ECD and caregiving outcomes and assess program implementation quality as delivered through existing community-based peer groups. This study will provide rigorous evidence that can be used to inform scale-up of this program model that leverages existing community social networks and resources for improving caregivers’ parenting skills and promoting ECD in rural Kenya and other similar settings across LMICs.Trial registrationClinicalTrials.gov #NCT06165315. Registered on December 11, 2023.

Pilot Study Assessing the Baseline Physical Activity and Knowledge of Heart Health of Elementary School-Aged Children in Rural South Carolina and the Impact of an Interactive Educational Program.

This study asked whether, if provided with education on heart-healthy habits, elementary school children in Abbeville, Greenwood, and Saluda counties in South Carolina would retain and desire to implement healthy nutrition and increased exercise. We hypothesized that teaching children about heart-healthy habits would increase their activity levels and improve their desire to be active. This was a longitudinal survey study. Children at local after-school programs were given a pre-survey, the Kids' Activity and Nutrition Questionnaire (KAN-Q), to assess their activity levels, diet, and knowledge of heart health. The children had a 15-minute educational period followed by an interactive program. Students completed the same survey at each of the three sessions. A total of 44 children answered the survey questions at the beginning of each session. Out of the 10 behavioral questions, six indicated a favorable shift towards adopting healthier habits. Whole grain consumption increased to 71% from 32% (p<0.01). Vegetable consumption increased from 39% to 88%, and fruit consumption increased from 68% to 92% (p<0.01). There was a 30% decrease in the consumption of sugary drinks (p<0.01), and a reduction in hours watching television (p=0.05). All four knowledge-based questions had an increase in correct responses across the three sessions (p<0.01). To augment behavior, a dual approach of education on nutrition and exercise leads to improved nutrition choices and exercise habits for primary prevention of cardiovascular risk factors in elementary school-aged children. These habits improve adherence to increased physical activity and better nutrition after school.

Maternal perception on use of edible insects for complementary feeding and nutritional status of children in Kakamega and Siaya Counties, Kenya

Despite the high protein levels, essential fatty acids and minerals that are found in edible insects, they are still not being used in complementary feeding. The aim of this study was to investigate maternal perception on use of edible insects for complementary feeding and nutrition status of children in Kakamega and Siaya Counties, Kenya. The study adopted a cross-sectional analytical design which was used on a sample of 592 mother-child pairs (aged 6-23 months) in Kisa North, West Yimbo and West Ugenya wards. Majority of the mothers were in the childbearing age group of 15-49 years, were married and 57.9% in Kisa North, 65.7% in West Ugenya and 64.6% in West Yimbo had attained primary education. Generally, 50.9%, 54.2% and 48.8% of the household heads in Kisa North, West Ugenya and West Yimbo, respectively had attained primary education. About 49.5% and 38.9% of the mothers in Kisa North and West Ugenya practiced farming while 35.3% of those in West Yimbo engaged in business. About 40.3% of the household heads in West Ugenya were farmers, 48.7% in Kisa North were casual labourers while 66.3% in West Yimbo engaged in fishing. Approximately 42.1%, 33.7% and 39.3% of the mothers in Kisa North, West Ugenya and West Yimbo respectively disagreed about the use of edible insects for complementary feeding. More than half (65.3%, 56.6% and 61.7%) of the children in Kisa North, West Ugenya and West Yimbo respectively attained the Minimum Dietary Diversity. More than half (58.9% and 55.8%) of the children in West Yimbo and West Ugenya respectively and 29.7% in Kisa North attained the Minimum Acceptable Diet. In terms of nutrition status, the prevalence rates of wasting were (6.3% in West Ugenya, 7.0% in West Yimbo and 6.0% in Kisa North), stunting rates (19.5% in West Ugenya and an equal proportion of 19.9% in West Yimbo and Kisa North) and underweight rates (9.2% in West Ugenya, 9.0% in West Yimbo and 8.8% in Kisa North). There were significant relationships between the maternal perceptions of the appropriateness of insects in complementary food and the ward of residence (ꭓ²=16.86, p value=0.030), marital status of the mother (ꭓ²=11.14, p value=0.025), main source of income for the household head (ꭓ²=33.35, p value=0.007) and the education level of the household head (ꭓ²=48.67, p value=0.009). This information will be useful to the Ministry of Health through the division of nutrition for inclusion in the MIYCN policy the use of edible insects as a complementary food. Key words: Children, Complementary feeding, Edible Insects, Nutritional Status, Maternal Perception

A Comparative Case Study Analysis: Applying the HIPE Framework to Combat Harmful Health Information and Drive COVID-19 Vaccine Adoption in Underserved Communities.

This descriptive, observational paper utilizes the comparative case study approach to analyze the application of the HIPE™ Framework to two health campaigns addressing vaccine hesitancy in underserved communities. Exposure to inaccurate/misleading health information impacts vaccination adoption, especially for individuals with low health/digital literacy. Underserved groups-like minority, racial/ethnic, or rural populations-typically have lower literacy and higher rates of vaccine hesitancy. Grounded in persuasion and behavioral change theory, the Health Information Persuasion Exploration (HIPE™) Framework was applied to the Black/Haitian community in Miami-Dade, Florida and the Migrant Agricultural Worker Community in Central Valley, California. The campaigns addressed each community's unique characteristics via Detect, Analyze, Design, and Evaluate phases of the HIPE framework. Both campaigns achieved their respective vaccine uptake goals. For Miami-Dade, over 850 vaccinations were administered (the goal was 800 vaccinations), and vaccination rates increased by 25.22%. In Central Valley, vaccination rates for 5-11-year-old children in Merced and Stanislaus counties increased about 20% and 14%, respectively, and overall vaccination rates increased compared to surrounding counties. Discussion of the results and recommendations for future research highlight the potential efficacy of applying the HIPE™ Framework for developing health campaigns and response strategies to improve health outcomes.

Understanding factors responsible for the slow decline of soil-transmitted helminthiasis following seven rounds of annual mass drug administration (2012–2018) among school children in endemic counties of Kenya: A mixed method study

Soil-transmitted helminthiasis (STH) continue to be a significant health problem in Sub-Saharan Africa especially among school children. In Kenya, treatment of over five million children has been conducted annually in 28 endemic counties since the year 2012. However, the latest monitoring and evaluation (M&E) results indicated a slow decline of prevalence and intensity of STH in some counties after the seven rounds of annual mass drug administration (MDA). The current study sought to determine the factors associated with the slow decline in prevalence and intensity of STH among school children participating in the school deworming programme. Mixed methods cross-sectional study was conducted in three endemic counties of Kenya. For quantitative technique, simple random sampling was used to select 1,874 school children from six purposively selected primary schools. The school children were interviewed, and a single stool collected and analysed using Kato-Katz technique. While for qualitative methods, 15 focus group discussions (FGDs) were conducted with purposively selected parents/guardians of school children. Data was collected through voice records using FGD and analyzed using NVIVO. Prevalence of any STH infection was 30.8% (95%CI: 28.7-32.9), with the highest prevalence observed in Vihiga County (40.7%; 95%CI: 37.4-44.4). Multivariable analysis revealed that geographical location (OR = 3.78, (95%CI: 1.81-7.88) p<0.001), and not washing hands after defecation (OR = 1.91, (95%CI: 1.13-3.20) p = 0.015) were significantly associated with any STH infection. For qualitative analysis, majority of the parents/guardians of SAC felt that poor water sanitation and hygiene practices (WASH) both in school and household level could be a cause of continued STH infection. Also failing to include the rest of the community members in the MDAs were mentioned as possible contributors to observed slow decline of STH. There was moderate STH prevalence and mean intensity despite the seven rounds of repeated annual MDA. The study recommends a revamped awareness creation on WASH and community wide treatment.

Understanding the Effects of COVID-19 on Child Maltreatment Reporting Among Rural Versus Urban Communities in the United States

The onset of the coronavirus disease 2019 (COVID-19) pandemic impacted child protective services (CPS) reporting systems in the United States. It may have also led to widened gaps between rural and urban communities in child maltreatment (CM) report rates due to decreased interaction between children and mandated reporters especially in urban jurisdictions. Using data from the National Child Abuse and Neglect Data System, this study tests the hypothesis that during the onset of the COVID-19 pandemic, the decrease in CM reports made to CPS in urban counties was more pronounced than in rural counties. Reports of CM received by CPS offices between January 6, 2020 and June 28, 2020 were aggregated to per-county-per-week-per-10,000 children maltreatment report rates. We used changepoint analyses to analyze the inter- and intra-region incidence rate ratios among rural and urban counties. Moreover, we used multilevel random effects models to generate regression coefficients for the associations between rates of children with a maltreatment report, COVID-19 occurrence, rural-urban designation, and maltreatment risk factors. During the study period, rates of children with a maltreatment report among urban counties decreased more dramatically when compared with rural counties. Our findings persisted even with the inclusion of control variables associated with maltreatment risk factors. Social distancing restrictions may have had the unintended consequence of decreasing the visibility of at-risk children in urban counties more so than in rural counties. Considering geography is critical to continue to protect children during the COVID-19 pandemic and as we prepare for future disasters.

Application of ARIMA, and hybrid ARIMA Models in predicting and forecasting tuberculosis incidences among children in Homa Bay and Turkana Counties, Kenya.

Tuberculosis (TB) infections among children (below 15 years) is a growing concern, particularly in resource-limited settings. However, the TB burden among children is relatively unknown in Kenya where two-thirds of estimated TB cases are undiagnosed annually. Very few studies have used Autoregressive Integrated Moving Average (ARIMA), and hybrid ARIMA models to model infectious diseases globally. We applied ARIMA, and hybrid ARIMA models to predict and forecast TB incidences among children in Homa Bay and Turkana Counties in Kenya. The ARIMA, and hybrid models were used to predict and forecast monthly TB cases reported in the Treatment Information from Basic Unit (TIBU) system by health facilities in Homa Bay and Turkana Counties between 2012 and 2021. The best parsimonious ARIMA model that minimizes errors was selected based on a rolling window cross-validation procedure. The hybrid ARIMA-ANN model produced better predictive and forecast accuracy compared to the Seasonal ARIMA (0,0,1,1,0,1,12) model. Furthermore, using the Diebold-Mariano (DM) test, the predictive accuracy of ARIMA-ANN versus ARIMA (0,0,1,1,0,1,12) model were significantly different, p<0.001, respectively. The forecasts showed a TB incidence of 175 TB cases per 100,000 (161 to 188 TB incidences per 100,000 population) children in Homa Bay and Turkana Counties in 2022. The hybrid (ARIMA-ANN) model produces better predictive and forecast accuracy compared to the single ARIMA model. The findings show evidence that the incidence of TB among children below 15 years in Homa Bay and Turkana Counties is significantly under-reported and is potentially higher than the national average.

Access to Early Care and Education in Rural Communities: Implications for Children's School Readiness.

This study links county-level early care and education (ECE) program, economic, and demographic data to child-level data from the Early Childhood Longitudinal Study-Kindergarten Cohort of 2010-2011 to examine geographic variation in ECE program participation and provision. We find that public ECE programs, particularly Head Start, occupy a larger role in nonmetropolitan communities than in metropolitan areas. By contrast, children in rural counties are less likely to attend private center-based ECE, and nonprofit childcare program expenditures in rural areas lag. We also find rural-metropolitan differences in school readiness diminish when geographic characteristics are controlled. Results suggest that county-level context and state-level policy features shape children's early experiences, and that public ECE investments are key in narrowing disparities in ECE attendance and in children's outcomes.

Analysis of a Statewide Early Intervention Program for Young Children with ASD.

We evaluated the effectiveness of a statewide Medicaid program providing in-home Early Intensive Behavioral Intervention services to young children with Autism Spectrum Disorder living in a rural southern state. Program effectiveness was assessed via the Assessment of Basic Language and Learning Skills-Revised (ABLLS-R). A multi-level growth model was used to show significant variation among children's initial ABLLS-R scores and their growth trajectories. Hispanic children tended to have lower initial scores but demonstrated similar growth compared to their non-Hispanic peers. Children who were older at initial start in the program appeared to have higher initial composite scores and higher growth trajectories. Children in more populous counties had higher initial scores but grew at similar rates to children in more rural counties.

Association of Elementary School Reopening Status and County COVID-19 Incidence.

ObjectiveTo examine the association between elementary school opening status (ESOS) and changes in pediatric COVID-19 incidence.MethodsWe conducted a cross-sectional study of US counties with school districts with ≥500 elementary school students. The main exposure was ESOS in September, 2020. The outcome was county incidence of COVID-19. Age-stratified negative binomial regression models were constructed using county adult COVID-19 incidence.ResultsAmong 3220 US counties, 618 (19.2%) were remote, 391 (12.1%) were hybrid, 2022 (62.8%) were in-person. In unadjusted models, COVID-19 incidence after school started was higher among children in hybrid or in-person counties compared with remote counties. After adjustment for local adult incidence, among children aged 0 to 9, the incidence rate ratio of COVID-19 (IRR) compared with remote counties was 1.01 (95% confidence interval [CI] 0.93–1.08) in hybrid counties and 0.79 (95% CI 0.75–0.84) in in-person counties.ConclusionsCounties with in-person learning did not have higher rates of COVID-19 after adjustment for local adult rates.

Association of County-Level Availability of Pediatricians With Emergency Department Visits.

The relationship between pediatrician availability and emergency department (ED) attendance is uncertain. We determined whether children in counties with more pediatricians had fewer ED visits. We conducted a cross-sectional study of all ED visits among children younger than 18 years from 6 states. We obtained ED visit incidences by county and assessed the relationship to pediatrician density (pediatricians per 1000 children). Possible confounders included state, presence of an urgent care facility in the county, urban-rural status, and quartile of county-level characteristics: English-speaking, Internet access, White race, socioeconomic status, and public insurance. We estimated county-level changes in incidence by pediatrician density adjusting for state and separately for all possible confounders. Each additional pediatrician per 1000 children was associated with a 13.7% (95% confidence interval, -19.6% to -7.5%) decrease in ED visits in the state-adjusted model. In the full model, there was no association (-1.4%, 95% confidence interval, -7.2% to 4.8%). The presence of an urgent care, higher socioeconomic status score, urban status, and higher proportions of White race and nonpublic insurance were each associated with decreased ED visit rates. Pediatrician density is not associated with decreased ED visits after adjusting for other county demographic factors. Increasing an area's availability of pediatricians may not affect ED attendance.

Geography of mobility and parenting behavior in low income families

BackgroundThe geographic location of birth has implications for low-income children's upward economic mobility, as Chetty, Hendren, Kline, and Saez (2014) found in an examination of millions of income tax records from each county in the US. Additional work indicates that low income children in higher economic mobility counties have higher language scores and fewer behavioral problems (Donnelly et al., 2017). However, the processes by which the geography of opportunity influences parenting are less well-understood. ObjectiveThis study examines whether living in higher intergenerational mobility counties is associated with less harsh parenting, material hardship, household violence and substance use, and low child supervision – parenting behaviors that increase the risk for child maltreatment – for low-income families. DataData come from the Fragile Families and Child Wellbeing Study, a longitudinal birth cohort of low income families in 20 cities in the U.S (N ~, 2841; 76% lower (household income of $41,994 or less) and 24% higher-income) linked to county level data on intergenerational mobility from the Equality of Opportunity Project. MethodsWe estimate OLS and Linear Probability regressions of the association between (1) exposure to county-level intergenerational mobility and (2) number of waves of exposure to county intergenerational mobility 1 standard deviation above the mean and maternal parenting behaviors. ResultsA 1 standard deviation increase in county level intergenerational mobility is associated with decreases in harsh parenting, but not indicators of neglect. Longer exposure to high intergenerational mobility areas was associated with decreased maternal harsh parenting and risk for child maltreatment. ConclusionsFor low-income children, higher intergenerational mobility is associated with decreased risk of harsh parenting, particularly at younger ages, as is longer exposure to high intergenerational mobility areas. That lower-income families are less likely to live in economically mobile geographies may exacerbate inequalities among income groups.

Socioeconomic disparities in survival after high-risk neuroblastoma treatment with modern therapy.

Modern therapeutic advances in high-risk neuroblastoma have improved overall survival (OS), but it is unclear whether these survival gains have been equitable. This study examined the relationship between socioeconomic status (SES) and overall survival (OS) in children with high-risk neuroblastoma and whether SES-associated disparities have changed over time. In this population-based cohort study, children <18years diagnosed with high-risk neuroblastoma (diagnosis at age ≥12months with metastatic disease) from 1991 to 2015 were identified through the National Cancer Institute's Surveillance, Epidemiology, and End Results database. Associations of county-level SES variables and OS were tested with univariate Cox proportional hazards regression. For a subcohort diagnosed after 2007, insurance status was examined as an individual-level SES variable. Multivariable regression analyses with treatment era and interaction terms were performed when SES variables reached near-significance (p≤.1) in univariate and bivariate modeling with treatment era. Among 1217 children, 2-year OS improved from 53.0 ± 3.4% in 1991-1998 to 76.9 ± 2.9% in 2011-2015 (p<.001). In univariate analyses, children in high-poverty counties (hazard ratio [HR]=1.74, 95% confidence interval [CI]=1.17-2.60, p=.007), and those with Medicaid (HR=1.40, 95% CI=1.05-1.86, p=.02) experienced an increased hazard of death. No interactions between treatment era and SES variables were statistically significant in multivariable analyses, indicating that differences in the OS between SES groups did not change over time. Survival disparities among children with high-risk neuroblastoma have not widened over time, suggesting equitable access to and benefit from therapeutic advances. However, children of low SES experience persistently inferior survival. Interventions to narrow this disparity are paramount.

Geographic Evaluation of Georgia Vaccination Disparity Among Laboratory-Confirmed Influenza Cases in a Children’s Hospital

Background: Vaccination coverage among children aged ≤18 years in Georgia remains one of the lowest in the nation with 39.3% coverage. During the 2018–2019 influenza season, the CDC reported 142 pediatric deaths, 3 of which occurred in Georgia. In a time of increasing complexity of immunization schedules, increase severity with a high level of flu-related deaths and hospitalization, it is important to understand localized factors that contribute to decrease influenza immunization and increased flu-related hospital visits among children. Methods: Data include electronic medical record chart review of 5,827 laboratory confirmed Children’s Healthcare of Atlanta visitor cases from October 1, 2016, to September 24, 2019. System-wide county level data included 3 pediatric hospitals, 5 primary care facilities, 8 urgent care facilities, and 2 outpatient clinics. Characteristics associated with disparities in vaccine were explored using univariate and multiple regressions analysis. Of those children with a primary care physician (PCP), 30% had flu vaccinations, whereas only 16.5% of those without a PCP had been vaccinated (P ≤ .00001). There was a positive relationship between increased county influenza rate and percentage of children in county who were preschoolers &lt;5 years old (r = 0.93; P ≤ .05). Moreover, 78% of children who received the flu vaccine ≤ 2 weeks prior to a confirmed flu diagnosis got the flu during peak flu periods (r = 0.29; P ≤ .05). Predictors of increased flu rate per 1,000 children were associated with flu vaccines given ≤2 weeks before a lab confirmed flu diagnosis (P ≤ .02). Children in counties that had a higher rate of flu during the peak period also had an overall higher rate of flu (P ≤ .005). The higher the percentage of children who got flu during peak flu period, the lower the vaccination rate for the county (P ≤ .001). The percentage of children ≤18 years old with no health insurance was associated with lower vaccination rates in the county (P ≤ .004). There appears to be a positive relationship between receiving flu vaccine 2 weeks prior to lab-confirmed flu diagnosis and onset of illness during the peak flu periods. Missed opportunities to obtain a flu vaccine by a PCP were associated with increased flu-related hospital visits and lower vaccination rates. Results may support predischarge hospital vaccinations and the promotion of flu vaccination education. Pediatric research is needed to facilitate localized PCP vaccination or predischarge hospital vaccinations prior to peak flu periods when hospital-related flu visits increase.Funding: NoneDisclosures: None

Association of a School-Based, Asthma-Focused Telehealth Program With Emergency Department Visits Among Children Enrolled in South Carolina Medicaid

Telehealth may improve access to care for populations in rural communities. However, little is known about the effectiveness of telehealth programs designed for children. To examine the associations of a school-based telehealth program in Williamsburg county (South Carolina) with all-cause emergency department (ED) visits made by children enrolled in Medicaid. This Medicaid claims data analysis was conducted in Williamsburg county and 4 surrounding counties in South Carolina and included children aged 3 to 17 years who were enrolled in Medicaid and living in any of the 5 counties from January 2012 to December 2017. Williamsburg served as the intervention and the 4 surrounding counties without a telehealth program as the control; 2012 to 2014 was designated as the preintervention period, whereas 2015 to 2017 served as the postintervention period. The study was designed with a difference-in-differences specification, in which the unit-of-analysis was a child-month, and a subsample included children with asthma. The data analysis was performed from July 2018 to February 2019. The school-based telehealth program implemented in Williamsburg county in 2015. The binary outcome was the status of at least 1 all-cause ED visit by a child in a given month. The full sample included 2 443 405 child-months from 23 198 children in Williamsburg county and 213 164 children in the control counties. The mean (SD) proportions of monthly ED visits in Williamsburg were 3.65% (0.10%) during the preintervention and 3.87% (0.11%) during the postintervention. The corresponding proportions of the 4 control counties were 3.37% preintervention (0.04%), and 3.56% postintervention (0.04%), respectively. The trends in the proportion were paralleled. In the asthma subsample, the proportions in Williamsburg were 3.16% (0.31%) during the preintervention and 3.38% (0.34%) during the postintervention, respectively. The proportions for the control counties were 3.02% preintervention (0.10%) and 3.90% postintervention (0.11%), respectively. There was an interaction of the proportions between the pre/postintervention period and the intervention/control counties in this subsample. The regression analysis of the full sample showed no association of the telehealth program with ED visits. The additional analysis of the asthma subsample showed that this program was associated with a reduction of 0.66 (95% CI, -1.16 to -0.17; P < .01) percentage point per 100 children per month in ED visits, representing an approximately 21% relative decrease. Although we found no association of this program with the ED visits of the overall studied population, this study suggests that telehealth with a focus on chronic pediatric diseases, such as asthma, may deliver substantial health benefits to rural and medically underserved communities.

Math and Chinese-Language Learning

This paper seeks to understand the learning outcomes that prevail across key subpopulations in China today. Data from a nationally representative survey show that rural youth are two years behind urban children in math and Chinese. Non-Han minorities, children in poorer counties, and children with less-educated parents are the most vulnerable.

Geographic Access to International Board-Certified Lactation Consultants in Pennsylvania.

Availability of professional lactation support has been associated with increased breastfeeding rates; however, data about access to international board-certified lactation consultants are limited. The aims were (a) to assess geographic access to international board-certified lactation consultants in Pennsylvania, (b) to compare access in rural/urban counties, and (c) to compare access by county-level breastfeeding initiation rates. Using geographic information systems methodology and a cross-sectional observational design, we calculated the proportion of young children living within 15, 30, and 60 miles of international board-certified lactation consultants in Pennsylvania. We calculated these proportions for all children in Pennsylvania, for children in urban and rural counties, and for children in counties with low, medium, and high breastfeeding initiation rates. Comparisons were done to answer the research aims. Over 90% of young children live within 30 miles of an international board-certified lactation consultant. Compared to children in urban counties, fewer children in rural counties live within 15 and 30 miles of these providers. In counties with high breastfeeding initiation rates, a larger percentage of children live within 15 miles of an international board-certified lactation consultant than in counties with low breastfeeding initiation rates. While most Pennsylvania children live in proximity of an international board-certified lactation consultant, this was true for a lower percentage of children in rural counties and in counties with lower breastfeeding rates.

Does Public School Spending Raise Intergenerational Mobility? Evidence from U.S. School Finance Reforms

This study examines whether investment in public schools can enhance equality of opportunity as measured by intergenerational income mobility (IGM). To estimate the causal effect of public school spending, I exploit the plausibly exogenous variation in school spending induced by the U.S. court-mandated school finance reforms. I use county-level college attendance rate and IGM constructed based on administrative tax records. Students are more likely to attend college due to additional resources in public schools. An increase in school spending raises IGM of children from high-income families. However, public school spending has little impact on IGM of low-income children. The school spending effects are concentrated among low-poverty counties. In particular, I find a significant increase in IGM of low-income children in low-poverty counties, which implies that the positive effect of school spending might be mitigated by negative environments in high poverty areas.

The Effect of Pediatric Palliative Care Policy on Hospice Utilization Among California Medicaid Beneficiaries

ContextCalifornia implemented pediatric palliative care legislations that allowed children to receive curative and supportive care from diagnosis of a life-threatening serious illness in 2010. Palliative care policies may improve access to hospice care as children near end of life. ObjectivesThe aim of this study was to examine the effect of the palliative care policy on hospice utilization for children and their families was investigated. MethodsUsing 2007 and 2010 California Medicaid data, a difference-in-difference analysis was conducted to analyze hospice use (i.e., hospice enrollment, hospice length of stay) changes for children who resided in pediatric policy counties relative to those who did not. The sample of children in California who died with a life-threatening serious illness in 2007 and 2010 equaled 979 children. ResultsMore than 10% of children enrolled in hospice care with an average of less than 3 days of hospice care. The palliative care policy did not have any effect on hospice enrollment. However, the policy was positively associated with increasing days in hospice care (incidence rate ratio = 5.61, P < 0.05). The rate of hospice length of stay increased by a factor of 5.61 for children in palliative care counties compared with children unaffected by the policy. ConclusionThe pediatric palliative care policy was associated with longer lengths of stay in hospice once the children were enrolled. Policies promoting palliative care are critical to ensuring access to hospice care for children.

Household survey analysis of the impact of comprehensive strategies to improve the expanded programme on immunisation at the county level in western China, 2006–2010

ObjectiveTo evaluate interventions to improve routine vaccination coverage and caregiver knowledge in China's remote west, where routine immunisation is relatively weak.DesignProspective pre–post (2006–2010) evaluation in project counties; retrospective comparison based...