BACKGROUND: Low-income and marginalized adults disproportionately bear the burden of poor asthma outcomes. One consequence of the structural racism which preserves these inequities is decreased trust in government and healthcare institutions.

OBJECTIVE: We examined whether such distrust extends to health care providers during the pandemic.

METHODS: We enrolled adults living in low-income neighborhoods who had had a hospitalization, ED visit, or prednisone course for asthma in the prior year. Trust was a dichotomized measure derived from a 5-item questionnaire with a 5-point Likert scale response The items were translated to a binary variable "strong" versus "weak" trust. Communication was measured using a 13-item questionnaire with a 5-point Likert scale. Logistic regression was used to examine the association between communication and trust, controlling for potential confounders.

RESULTS: We enrolled 102 patients, 18-78 years, 87% female, 90% Black, 60% some post-high school education, 57% receiving Medicaid. 58 patients were enrolled prior to the March 12, 2020 pandemic start date. 70 (68%) patients named doctors as their most trusted source of health information. Strong trust was associated with a negative response to: "It is hard to reach a person in my doctor's office by phone." There was no evidence of an association between the overall communication scores and trust. Satisfaction with virtual messaging was weaker among those with less trust.

CONCLUSIONS: These patients trust their physicians, value their advice, and need to have accessible means of communication.

Globally, mental health problems have been reported to be more common in youth living with HIV (YLWH) than in the general population, but routine mental health screening is rarely done in high-volume HIV clinics. In 2019, YLWH in a large HIV clinic in Botswana were screened using the Generalized Anxiety Scale-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) in a pilot standard-of-care screening programme. Two-way ANOVA was used to describe the effects of age group (12-<16, 16-<20 and 20-25 years old) and sex on GAD-7 and PHQ-9 scores. Chi-square statistics were used to compare characteristics of YLWH with and without potential suicidality/self-harm symptoms based on question 9 in the PHQ-9. Among 1 469 YLWH, 33.1%, 44.3% and 15.0% had anxiety, depression and potential suicidality/self-harm symptoms respectively. YLWH of 20-25 years old and 16-<20 years old had higher GAD-7 scores compared to 12-<16-year-olds ( = 0.014 and = <0.001 respectively). Female YLWH of 20-25 years old had higher PHQ-9 scores compared to 12-<16-year-olds ( = 0.002). There were no other sex-age dynamics that were statistically significant. Female YLWH endorsed more thoughts of suicidality/self-harm than males (17% versus 13%, = 0.03 respectively). Given the proportion of YLWH with mental health symptoms, Botswana should enhance investments in mental health services for YLWH, especially for young female adults who bear a disproportionate burden.

OBJECTIVES: To test effects of a social media-based parenting program for mothers with postpartum depressive symptoms.

METHODS: We conducted a randomized controlled trial from December 2019 to August 2021 of a parenting program using Facebook. Women with mild-to-moderate depressive symptoms (Edinburgh Postnatal Depression Scale [EPDS] 10-19) were randomized to the program, plus online depression treatment or depression treatment alone for 3 months. Women completed the EPDS monthly and the Parent-Child Early Relational Assessment, Parenting Stress Index-Short Form, and Parenting Sense of Competence pre- and postintervention. Differences among groups were assessed using intention-to-treat analysis.

RESULTS: Seventy-five women enrolled and 66 (88%) completed the study. Participants were predominantly Black (69%), single (57%), with incomes <$55 000 (68%). The parenting group reported a more rapid decline in depressive symptoms than the comparison group (adjusted EPDS difference, -2.9; 95% confidence interval, -4.8 to -1.0 at 1 month). There were no significant group X time interactions for the Parent-Child Early Relational Assessment, Parenting Stress Index-Short Form, or Parenting Sense of Competence scores. Forty-one percent of women sought mental health treatment for worsening symptoms or suicidality. Women in the parenting group who exhibited greater engagement or reported mental health treatment had greater parenting responsiveness.

CONCLUSIONS: A social media-based parenting program led to more rapid declines in depressive symptoms but no differences in responsive parenting, parenting stress, or parenting competence relative to a comparison group. Social media can provide parenting support for women with postpartum depressive symptoms, but greater attention to engagement and treatment access are needed to improve parenting outcomes.

OBJECTIVE: Determine the optimal combination of digital health intervention component settings that increase average sleep duration by ≥30 minutes per weeknight.

METHODS: Optimization trial using a 2 factorial design. The trial included 2 week run-in, 7 week intervention, and 2 week follow-up periods. Typically developing children aged 9-12y, with weeknight sleep duration <8.5 hours were enrolled (N=97). All received sleep monitoring and performance feedback. The five candidate intervention components ( ) were: 1) sleep goal ( ); 2) screen time reduction messaging ( ); 3) daily routine establishing messaging ( ); 4) child-directed loss-framed financial incentive ( ); and 5) caregiver-directed loss-framed financial incentive ( ). The primary outcome was weeknight sleep duration (hours per night). The optimization criterion was: ≥30 minutes average increase in sleep duration on weeknights.

RESULTS: Average baseline sleep duration was 7.7 hours per night. The highest ranked combination included the core intervention plus the following intervention components: sleep goal (either setting was effective), caregiver-directed loss-framed incentive, messaging to reduce screen time, and messaging to establish daily routines. This combination increased weeknight sleep duration by an average of 39.6 (95% CI: 36.0, 43.1) minutes during the intervention period and by 33.2 (95% CI: 28.9, 37.4) minutes during the follow-up period.

CONCLUSIONS: Optimal combinations of digital health intervention component settings were identified that effectively increased weeknight sleep duration. This could be a valuable remote patient monitoring approach to treat insufficient sleep in the pediatric setting.

<p>Children living with&nbsp;HIV (HIV+) experience increased risk of&nbsp;neurocognitive deficits, but standardized&nbsp;cognitive testing is limited in low-resource, high-prevalence settings. The Penn Computerized Neurocognitive Battery (PennCNB) was adapted for use in Botswana.&nbsp;This&nbsp;study evaluated the criterion validity of a locally adapted version of the PennCNB among a cohort of HIV+ individuals aged 10-17&nbsp;years in Botswana.&nbsp;Participants completed the PennCNB and a comprehensive professional consensus assessment consisting of pencil-and-paper psychological assessments, clinical interview, and review of academic performance. Seventy-two&nbsp;participants were&nbsp;classified as cases (i.e., with cognitive impairment; N = 48) or controls (i.e., without cognitive impairment; N = 24). Sensitivity, specificity, positive predictive value, negative predictive value, and the area under receiver operating&nbsp;characteristic curves were&nbsp;calculated. Discrimination was acceptable, and prediction improved as the threshold for PennCNB impairment was less conservative. This research contributes to the validation of the PennCNB for use among children affected by HIV in Botswana.</p>

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<p><strong>BACKGROUND AND OBJECTIVES: </strong>Multiple strategies are used to identify newborn infants at high risk of culture-confirmed early-onset sepsis (EOS). Delivery characteristics have been used to identify preterm infants at lowest risk of infection to guide initiation of empirical antibiotics. Our objectives were to identify term and preterm infants at lowest risk of EOS using delivery characteristics and to determine antibiotic use among them.</p>

<p><strong>METHODS: </strong>This was a retrospective cohort study of term and preterm infants born January 1, 2009 to December 31, 2014, with blood culture with or without cerebrospinal fluid culture obtained ≤72 hours after birth. Criteria for determining low EOS risk included: cesarean delivery, without labor or membrane rupture before delivery, and no antepartum concern for intraamniotic infection or nonreassuring fetal status. We determined the association between these characteristics, incidence of EOS, and antibiotic duration among infants without EOS.</p>

<p><strong>RESULTS: </strong>Among 53 575 births, 7549 infants (14.1%) were evaluated and 41 (0.5%) of those evaluated had EOS. Low-risk delivery characteristics were present for 1121 (14.8%) evaluated infants, and none had EOS. Whereas antibiotics were initiated in a lower proportion of these infants (80.4% vs 91.0%, P &lt; .001), duration of antibiotics administered to infants born with and without low-risk characteristics was not different (adjusted difference 0.6 hours, 95% CI [-3.8, 5.1]).</p>

<p><strong>CONCLUSIONS: </strong>Risk of EOS among infants with low-risk delivery characteristics is extremely low. Despite this, a substantial proportion of these infants are administered antibiotics. Delivery characteristics should inform empirical antibiotic management decisions among infants born at all gestational ages.</p>

<p><strong>BACKGROUND: </strong>Fasting hypoglycemia is a recognized occurrence among pediatric patients with acute lymphoblastic leukemia (ALL) during maintenance therapy. Existing publications describing this finding are limited to small studies and case reports. Our objective was to determine the incidence of hypoglycemia during maintenance chemotherapy and to investigate the association of age, as well as other potential risk factors, with this outcome in pediatric patients with ALL.</p>

<p><strong>PROCEDURE: </strong>This retrospective cohort study included individuals 1 to 21 years of age with ALL treated with antimetabolite-containing maintenance chemotherapy at a large children's hospital between January 2011 and December 2014. The primary endpoint was time to first documented episode of hypoglycemia during maintenance therapy, defined as single measurement of plasma glucose&nbsp;&lt;60&nbsp;mg/dL. Cox regression was used to evaluate the association with age and identify other potential risk factors.</p>

<p><strong>RESULTS: </strong>We identified 126 eligible patients, of whom 63% were documented as White, non-Hispanic, 28% as non-White, non-Hispanic, and 9% as Hispanic. Twenty-eight children (22%) had documented hypoglycemia during maintenance therapy. Younger age at the start of maintenance and hepatotoxicity documented during chemotherapy prior to maintenance initiation were associated with hypoglycemia (adjusted HR age&nbsp;=&nbsp;0.88; 95% CI, 0.78-0.99; adjusted HR prior hepatotoxicity&nbsp;=&nbsp;3.50; 95% CI, 1.47-8.36).</p>

<p><strong>CONCLUSIONS: </strong>Nearly one quarter of children in our cohort had hypoglycemia documented during maintenance chemotherapy. Younger age at maintenance initiation and hepatotoxicity during chemotherapy prior to maintenance initiation emerged as risk factors. These findings highlight the importance of counseling about the risk of, and monitoring for, hypoglycemia, particularly in young children.</p>

<p>Children born to mothers infected with the human immunodeficiency virus (HIV) during pregnancy experience increased risk of neurocognitive impairment. In Botswana, HIV infection is common among youth, but standardized cognitive screening is limited. The Penn Computerized Neurocognitive Battery (PennCNB), a tool that streamlines evaluation of neurocognitive functioning, was culturally adapted for use among youth in this high-burden, low-resource setting. The present study examined the structural validity of the culturally adapted PennCNB. A cohort of 7-17-year-old children living with HIV (HIV +) and HIV-exposed-uninfected (HEU) children were enrolled from the Botswana-Baylor Children's Clinical Centre of Excellence in Gaborone, Botswana. Confirmatory and exploratory factor analyses were performed on speed, accuracy, and efficiency measures for 13 PennCNB tests. Fit of the confirmatory factor analysis was acceptable, which supports the design of the battery measuring four neurocognitive domains: Executive functioning, episodic memory, complex cognition, and sensorimotor/processing speed. However, the model revealed high interfactor correlation. Exploratory factor analysis suggested that tests assessing executive functioning and sensorimotor/processing speed clustered together rather than forming differentiable factors. Overall, this research provides valuable insight into the structural validity of a neurocognitive battery adapted for use in a non-Western setting, suggesting that the PennCNB could serve as a useful tool for the assessment of neurocognitive function in Botswana and, potentially, other resource-limited settings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).</p>

<p><strong>STUDY OBJECTIVES: </strong>Over 75% of US high school students obtain insufficient sleep, placing them at risk for adverse health outcomes. Identification of modifiable determinants of adolescent sleep is needed to inform prevention strategies, yet little is known about the influence of the built environment on adolescent sleep.</p>

<p><strong>METHODS: </strong>In this prospective study, actigraphy was used to assess sleep outcomes among 110 adolescents for 14 days each in eighth and ninth grades: duration (hours/night), onset and offset, and sleeping ≥8 hours. Home addresses were linked to built environment exposures: sound levels, tree canopy cover, street density, intersection density, population density, and housing density. Mixed-effects regression estimated associations of built environment measures with sleep outcomes, adjusting for sex, race, parent education, household income, household size, grade, weeknight status, and neighborhood poverty.</p>

<p><strong>RESULTS: </strong>A 1-standard deviation (SD) increase in neighborhood sound was associated with 16 minutes later sleep onset (β = 0.28; 95% confidence interval (CI): 0.06, 0.49) and 25% lower odds of sleeping for ≥8 hours (odds ratio (OR) = 0.75, 95% CI: 0.59, 0.96). A 1-SD increase in neighborhood tree canopy was associated with 18 minutes earlier sleep onset (β = -0.31, 95% CI: -0.49, -0.13) and 10 minutes earlier sleep offset (β= -0.17, 95% CI: -0.28, -0.05). No associations were observed for density-based exposures.</p>

<p><strong>CONCLUSIONS: </strong>Higher neighborhood sound level was associated with lower odds of sufficient sleep, while higher tree canopy cover was associated with more favorable sleep timing. Neighborhood sound levels and tree canopy cover are potential targets for policies and interventions to support healthier sleep among adolescents.</p>

<p><strong>BACKGROUND: </strong>Pediatricians lack tools to support families at home for the promotion of childhood sleep. We are using the Multiphase Optimization Strategy (MOST) framework to guide the development of a mobile health platform for childhood sleep promotion.</p>

<p><strong>PURPOSE: </strong>Under the preparation phase of the MOST framework, to demonstrate feasibility of a mobile health platform towards treating children with insufficient sleep.</p>

<p><strong>METHODS: </strong>Children aged 10-12y were enrolled (Study #1: N=30; Study #2: N=43). Participants wore a sleep tracker to measure sleep duration. Data were retrieved by a mobile health platform, programmed to send introductory messages during run-in (2 weeks) and goal achievement messages during intervention (7 weeks) periods. In study #1, participants were randomized to control, gain-framed incentive or loss-framed incentive arms. In study #2, participants were randomized to control, loss-framed incentive, normative feedback or loss-framed incentive plus normative feedback arms.</p>

<p><strong>RESULTS: </strong>In study #1, 1,514 nights of data were captured (69%) and sleep duration during the intervention was higher by an average of 21 (95% CI: -8, 51) and 34 (95% CI: 7, 61) minutes per night for the gain-framed and loss-framed arms, respectively, compared to controls. In study #2, 2,689 nights of data were captured (81%), with no major differences in average sleep duration between the control and the loss-framed or normative feedback arms.</p>

<p><strong>CONCLUSION: </strong>We have developed and deployed a mobile health platform that can capture sleep data and remotely communicate with families. Promising candidate intervention components will be further investigated under the optimization phase of the MOST framework.</p>