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Background: We aimed to better understand the impact of statewide legislation removing personal belief exemptions (PBEs) for the measles, mumps, and rubella (MMR) school immunization requirement and factors associated with resulting health-seeking behaviors. Methods: We used chi-squared tests and logistic regression models to determine individual- and school-level characteristics associated with holding a MMR PBE and with post-law MMR immunization status among students linked to the Washington State Immunization Information System. Results: Of students with a MMR PBE pre-law change, 43.0% completed the MMR vaccine series and 40.4% sought another exemption type. Religious exemptions made up most new MMR exemptions signed (71.8%), followed by medical exemptions (18.5%), and religious membership exemptions (9.7%). Students were more likely to complete the vaccine series post-law change if they attended a school with a low school-level MMR exemption rate, a public school, or held a lower number of school-required immunization exemptions. Conclusions: This study confirms previous concerns that parents might replace their PBE with another exemption type; however, nearly half the students in the cohort completed the MMR vaccine series. Our findings suggest that targeted immunization policies can increase MMR coverage 1-year post-law change but must account for a replacement effect when exemption categories are eliminated.

Postpartum depression is a significant public health issue that occurs within the first 12 weeks after childbirth. It is more prevalent among teenage mothers compared to adults. However, the findings of the existing interventional studies cannot be readily applied to teenage mothers due to their unique psychosocial concerns. Furthermore, these findings have shown inconsistencies regarding the benefit of psychological and psychosocial interventions in reducing the incidence of postpartum depression. The current review is aimed at investigating the effectiveness of psychosocial interventions in preventing postpartum depression, specifically among teenage mothers. The preferred reporting items for systematic reviews and meta-analysis manuals were utilized to identify and select relevant articles for this review. The articles were retrieved using population, intervention, control, and outcome models. The quality of each article was assessed using the Cochrane risk of bias tool. Statistical analysis was conducted using STATA version 17. The effect size of the intervention was estimated using the standard mean difference in depression scores between the intervention and control groups. Heterogeneity among the studies was assessed using the I[superscript 2] statistic and Q statistic, while publication bias was evaluated through funnel plot asymmetry and Egger's test. A total of nine eligible articles were included. While psychosocial interventions have been demonstrated to decrease the incidence of postpartum depression compared to usual maternal health care, it is worth noting that the mean difference in depression scores was significant in only three of the included studies. The meta-analysis revealed that psychosocial interventions were effective at preventing postpartum depression, with a pooled effect size of -0.5 (95% CI: -0.95, -0.06) during the final postpartum depression assessment. The heterogeneity was substantial, with an I[superscript 2] value of 82.3%. Although publication bias was not observed, small studies had a significant effect on the pooled effect size. The findings of this review suggest that psychosocial interventions can effectively prevent PPD, particularly within the first 3 months of the postpartum period. This review highlights the scarcity of interventional studies in low-income countries, indicating the need for further research in diverse communities.

Community-engaged patient navigation safety net programs are established as an evidence-based approach to address cancer prevention and early detection efforts, but barriers to expand and sustain such programs persist. In addition, few studies describe how these programs impact buy-in among communities and policy change within health care systems and government. We describe how we used the Capacity for Sustainability Framework to guide efforts for program sustainability and community, institutional, and policy level change in a breast cancer screening and patient navigation safety net program. The nine domains of the Capacity for Sustainability Framework were used to develop program logic models, to inform program implementation and quality improvement agendas, and to guide multi-level partner and stakeholder engagement, outreach, and dissemination of outcomes. The program is currently in its seventh year and continues to be annually funded by a city public health department. In 2021, additional 5-year renewable funding from a state public health department was secured. In addition, institutional program support was expanded for patients diagnosed with breast cancer. Program leaders worked with policymakers to draft legislation to support training certification and third-payor reimbursement for patient navigators and community health workers. The program is well-known and trusted among community members, community-based organizations, and providers. Community, organizational, and policy-level outcomes demonstrate that community-engaged patient navigation safety net programs can influence more than individual and interpersonal outcomes and can be sustained over time.

The emerging field of genomic medicine offers an opportunity for biology and anatomy teachers to bring the topics of DNA, genetics, molecular processes, and evolution together into one experience. Through the genomic medicine paradigm, students see the unbroken connection between small biological topics such as mutations and their potential connection to disease phenotypes. In this paper, we present as a main example cystic fibrosis, which is an often-studied genetic disease in general biology class, for examination through the genomic medicine lens. Concepts such as genes, the plasma membrane, variation, mutations, the nucleus, and chromosomes can be used in a narrative and visual approach to genetics through the genomic medicine standpoint to engage and connect students with next-generation genomics and with the fundamental unit of life -- the cell. It is through the genomic medicine lens that the cell's context and relationship to the evolving world takes place.

Background: HPV is associated with several cancers, yet HPV vaccine uptake rates remain suboptimal. Enhancing HPV vaccine promotion requires looking beyond individual characteristics and conducting a thorough evaluation of how health-related and health system factors may influence HPV vaccine uptake. Purpose: Our study explores the relationship of health-related and health-system factors with patient-centered communication, HPV-related knowledge, and perceived effectiveness of the HPV vaccine. Methods: We used data from HINTS 5, Cycle 1, and performed structural equation modeling to explore the impact of health-related and health system factors on perceived HPV vaccine effectiveness, both directly and via HPV knowledge and patient-centered communication. The predictors in our model included health-related factors and health-system factors. Results: Findings suggest a direct relationship between HPV knowledge and perceived vaccine effectiveness ([beta] = 0.73; p < 0.05), and patient-centered communication and perceived vaccine effectiveness ([beta] = 0.07; p < 0.05). Frequency of doctor visits directly and negatively predicted patient-centered communication ([beta] = -0.04, p < 0.05). Self-reported health status was directly and positively related to HPV vaccine acceptability ([beta] = 0.147, p < 0.05). Having a chronic condition ([beta] = -0.09, p =< 0.05) and depression/anxiety ([beta] = 0.141, p < 0.05) was related to HPV vaccine acceptability, via knowledge. Discussion: These findings enhance our nuanced understanding of the intricate interplay between health-related and health-system factors in shaping perceptions and attitudes toward HPV vaccination. Translation to Health Education Practice: Accounting for health-related and health system factors is essential for effective dissemination of HPV information.

This paper presents an analysis of the socio-scientific dimensions which 46 11th graders, enrolled in the subject scientific culture, consider to justify their COVID-19 vaccination decision and how they managed to combine and integrate these dimensions before and after working on a sequence of activities aimed at learning about argumentation in science. Although almost all the students intended to be vaccinated against COVID-19, the results show that before the sequence, they used one or two dimensions to justify their decision, while after it, some combined up to five dimensions. The ethical and social-cultural dimensions were two of the most frequently used. The scientific dimension was infrequent in the initial argument but was, however, the most used dimension in the final argument, after the intervention. Working on socioscientific issues encourages the development of argumentation skills, and, in this specific case, health education skills as well.

Physical activity promotion is a best buy for public health because it has the potential to help individuals feel better, sleep better, and perform daily tasks more easily, in addition to providing disease prevention benefits. There is strong evidence that individual-level theory-based behavioral interventions are effective for increasing physical activity levels in adult populations but causal inference from these interventions often is unclearly articulated. A directed acyclic graph (DAG) can be, but rarely is, used to determine if the causal effect of an individual-level theory-based physical activity-promoting intervention is identifiable (e.g. stripped of any spurious association). The primary objective of the current study was to demonstrate how a DAG can be used to determine if the total causal effect of an individual randomized physical activity-promoting intervention is identifiable. The demonstration was based on the Well-Being and Physical Activity study (ClinicalTrials.gov, identifier: NCT03194854). Annotated files from DAGitty and Mplus are provided.

Background: Low adolescent HPV vaccination initiation due to parents declining vaccination remains a challenge for providers. In 2018, 65% of adolescent girls and 56% of adolescent boys in Texas initiated HPV vaccination. Gaps between HPV vaccination rates and those for Tdap (83%) and meningococcal vaccines (87%) among 13-17 year olds highlights missed opportunities to prevent HPV-related cancers. While leading medical organizations endorse a presumptive, bundled recommendation, in which the provider presents HPV vaccination the same way as other vaccines, bundled between Tdap and meningococcal at 11- or 12-year-old visits, provider recommendations vary. Methods: In 2015, we surveyed pediatricians in a large Texas pediatric clinic network to assess physician knowledge, beliefs, attitudes and behaviors regarding adolescent HPV vaccination. To ascertain HPV vaccination outcomes, survey data were merged with patient electronic health records. We examined the association of pediatrician HPV vaccination recommendation and vaccination using multivariable multilevel generalized linear models clustered by physicians. Adjusted odds ratios were calculated. Results: Among 226 physicians, 59.8% completed the emailed survey. Controlling for patient and physician demographics, odds of HPV vaccination initiation were significantly increased if physicians used a bundled approach to recommend the HPV vaccine: "Your child is due for three vaccines: Tdap, HPV, and meningococcal vaccine" versus "Your child is due for two vaccines, Tdap and meningococcal. There is also the HPV vaccine, which is optional" (OR: 1.59, 95% CI 1.30-1.96). Conclusion: This study links physician HPV vaccine recommendation wording and outcomes, showing the significant effect of bundling HPV vaccination for adolescent patients.

Health care reaches more children under age three in the United States than any other family-facing system and represents the most common entry point for developmental assessment of and services for children. In this article, Adam Schickedanz and Neal Halfon examine how well the child health care system promotes healthy child development early in life. They also review children's access to health care through insurance coverage, the health care system's evolution in response to scientific and technical advances, and the shifting epidemiology of health and developmental risk. The authors find that the health care system is significantly underperforming because it is constrained by antiquated conventions, insufficient resources, and outmoded incentive structures inherent in the traditional medical model that still dominates pediatric care. These structural barriers, organization challenges, and financial constraints limit the system's ability to adequately recognize, respond to, and, most importantly, prevent adverse developmental outcomes at the population level. To achieve population-level progress in healthy child development, Schickedanz and Halfon argue that pediatric care will need to transform itself and go beyond simply instituting incremental clinical process improvement. This will require taking advantage of opportunities to deliver coordinated services that bridge sectors and focusing not only on reducing developmental risk and responding to established developmental disability but also on optimizing healthy child development before developmental vulnerabilities arise. New imperatives for improved population health, along with the growing recognition among policy makers and practitioners of the social and developmental determinants of health, have driven recent innovations in care models, service coordination, and coverage designs. Yet the available resources and infrastructure are static or shrinking, crowded out by rising overall health care costs and other policy priorities. The authors conclude that child health systems are at a crossroads of conflicting priorities and incentives, and they explore how the health system might successfully respond to this impasse.

Objective: To identify predictors of meningococcal vaccine uptake among university and college students, the most common carriers of meningococcal disease. Participants: University or college students aged 18 to 25 years. Methods: Multiple databases, citations, and gray literature were systematically searched in April 2017 and January 2019, for articles reporting rates and predictors of vaccine uptake. Included studies underwent quality appraisal, and, where suitable, meta-analyses were performed. Results: Twenty-one articles, covering 18 studies from six countries, were included. They were mostly cross-sectional surveys of routine vaccination. Meta-analyses were conducted on six predictors. Higher vaccination uptake was associated with being a first year student, an undergraduate student, not being an international student, perceiving meningococcal disease as a risk, and being female. Conclusion: Identified key predictors correspond with previous studies and other vaccines. The findings should inform the delivery and communication of meningococcal vaccination to university and college students.

By highlighting the critical thinking that (1) analyzes and evaluates arguments for claims about vaccinations and autism, and (2) engages in a form of methodological skepticism that systematically and continuously asks Critical Questions, a philosophical approach is introduced to deal directly and systematically with students' (and publicly popular) misconceptions of (and resistance to) bio-medical knowledge, interventions, and/or technology employed in healthcare or public health. As a result of engaging in a dialogue between philosophy and the bio-medical sciences by means of critical thinking, the educator can help students actively compare their initial conceptions (and publicly popular misconceptions) with more fully scientific conceptions.

The indicators for health risk factors among school children in Lebanon associated with increased mortality and morbidity were higher than the global percentage based on WHO (2014) statistics. Knowing that the Ministry of Education in Lebanon has been trying to include health education in the national school curriculum since the last reform in 1997, this qualitative exploratory study analyzed the students' arguments resulting from focus group discussions to identify their level of knowledge, attitudes and perceptions and to provide suggestions for improving the national textbooks and teaching practices. Data were collected through focus group discussions with grade 5 students in 2 schools: Lebanese public school and UNRWA Palestinian School. The content analysis technique was used to perform the analysis and interpretation of data. Data was coded based on criteria from the Rational Model as well as the Health Belief Model. The study found, among other things, that students in both schools acquired the knowledge present in the textbooks about the benefits of balanced nutrition but they gave inaccurate and incomplete justifications with no scientific reasoning. Regarding attitudes, they show negative attitudes toward prefer unhealthy food over healthy ones. Some of their practices were healthy but unhealthy snacks, skipping breakfast, drinking big amounts of soft drinks were prevalent. The arguments of the students in both schools also showed some social related practices as related to the opinions, behavior, advice, and support of the people surrounding students influence their feelings and behavior, and the students have a reciprocal effect on those people.

Youth with autism spectrum disorder often have complex medical needs. Disruptions of healthcare during the transition from pediatric to adult healthcare may put youth with autism spectrum disorder at higher risk of medical emergencies and high medical costs. We conducted a study among transition-age youth (14-25 years old) receiving healthcare at Kaiser Permanente Northern California during 2014-2015. We examined the differences in healthcare utilization and costs among youth with autism spectrum disorder (n = 4123), attention deficit and hyperactivity disorder (n = 20,6015), diabetes mellitus (n = 2156), and general population controls (n = 20,615). Analyses were also stratified by age and sex. Youth with autism spectrum disorder had the highest utilization of outpatient primary care, mental health, and psychotropic medications and the lowest utilization of obstetrics/gynecology and urgent care. Costs for youth with autism spectrum disorder were higher than those for attention deficit and hyperactivity disorder and general population peers and lower than for diabetes mellitus. Utilization patterns varied by age. Transition-age youth with autism spectrum disorder generally utilize healthcare at higher rates relative to attention deficit and hyperactivity disorder and general population peers but at similar or lower rates than diabetes mellitus peers, indicating this group's complex combination of psychiatric and medical healthcare needs. The relatively high utilization of psychiatric services and low utilization of women's health services in transition-age youth with autism spectrum disorder may have implications for long-term health and warrants additional research.

Objective: The authors examined college students' experiences of providing peer-education, using the modified Social Network Strategy (SNS). Participants: Ninety-six college students participated this project during the 2018 academic year, drawn from a large, Mid-Southern urban university. Methods: Students who administered the HIV-PrEP health intervention completed a cross-sectional assessment about their experiences in the project. A series of open-ended prompts garnered written narrative responses. We utilized a qualitative content analysis to identify SNS codes and their frequencies. Results: Student responses were overwhelmingly supportive of the community engagement project. Student narratives featured the health communication intervention with peers most often (44.4%: counseling, testing, and referral communication), followed by influences on themselves (28.7%; what he/she learned, influences on student health and choices). Conclusions: A modified SNS demonstrated in this project reveals its utility in supporting undergraduates in the delivery of HIV/PrEP training in the 7th highest HIV transmission area in the nation.

Dental care received by children in the Autism Speaks Autism Treatment Network (ATN) was compared to National Survey of Children's Health (NSCH) data for children without special healthcare needs and children with parent-reported ASD. Correlates of obtained preventive dental services were examined within the ATN sample. Participants included 375 families of children ages 4 to 17 enrolled in the ATN. ATN families reported levels of preventive dental care that were similar to, or exceeded, NSCH-reported care. However, disparities in obtained preventive dental services emerged within the ATN sample. Lower intellectual functioning was the most consistent correlate of reduced access to and completion of preventive dental care. Implications for developing system-wide supports and targeted interventions are discussed.

It might seem strange to ask whether increasing access to medical care can improve children's health. Yet Lindsey Leininger and Helen Levy begin by pointing out that access to care plays a smaller role than we might think, and that many other factors, such as those discussed elsewhere in this issue, strongly influence children's health. Nonetheless, they find that, on the whole, policies to improve access indeed improve children's health, with the caveat that context plays a big role--medical care "matters more at some times, or for some children, than others." Focusing on studies that can plausibly show a causal effect between policies to increase access and better health for children, and starting from an economic framework, they consider both the demand for and the supply of health care. On the demand side, they examine what happens when the government expands public insurance programs (such as Medicaid), or when parents are offered financial incentives to take their children to preventive appointments. On the supply side, they look at what happens when public insurance programs increase the payments that they offer to health-care providers, or when health-care providers are placed directly in schools where children spend their days. They also examine how the Affordable Care Act is likely to affect children's access to medical care. Leininger and Levy reach three main conclusions. First, despite tremendous progress in recent decades, not all children have insurance coverage, and immigrant children are especially vulnerable. Second, insurance coverage alone doesn't guarantee access to care, and insured children may still face barriers to getting the care they need. Finally, as this issue of "Future of Children" demonstrates, access to care is only one of the factors that policy makers should consider as they seek to make the nation's children healthier.

Children with autism spectrum disorder (ASD) are at high risk for being overweight and obese. Little is known about how obesity in children with ASD is being addressed in primary care. This article reports findings from a survey completed by 327 general pediatricians, which included a fictional clinical vignette and Likert-scales assessing attitudes, practices, self-efficacy, and barriers to obesity management. Although the majority of respondents agreed pediatricians should be the main providers to manage obesity in children with ASD, few reported receiving adequate training to do so. Pediatricians were more likely to refer to developmental-behavioral pediatricians and dietitians for a child with ASD compared to a child without ASD. Higher self-efficacy was associated with increased weight-related counseling frequency by pediatricians.

This article looks at the process of compiling a community archive in Westbury, Johannesburg. The township is located alongside the better known Sophiatown. Its history provides an insight into the experiences of the working class in the city since the establishment of Johannesburg more than a 100 years ago. The motivation for this archive comes from the experiences of activists in dealing with social and economic challenges that this community continues to face, and the connection with past activism through the work of community activists like Florrie Daniels. Daniels kept meticulous records of community organisations she helped to establish around early childhood development, preventative healthcare, poverty alleviation, housing, sport, youth and women's organisations, as well as political and civic movements from the 1960s onwards. Much of what is contained in the Florrie Daniels collection is associated with cooperative grassroots activity. Her collection offers a perspective that includes records of working-class solidarity around regional and national social and political struggles. It forms the basis of further accumulation of materials to incorporate into a community archive. The idea of the archive has encouraged dialogue between veteran activists, organisations that operate in the area and education institutions that resulted in collaborative approaches in its construction.

ABSTRACTObjective: Complete and accurate documentation of immunization records and surveillance of disease transmission are critical to the public health response to outbreaks of communicable disease in institutions of higher education (IHEs). This study aims to describe immunization documentation practices and disease surveillance capacity among IHEs in Indiana in order to inform public health action. Methods: IHEs in Indiana were identified and included in the study if they offered on-campus housing and had a dedicated student health center. Phone surveys were administered in September 2015 to each institution, inquiring about current immunization documentation policies and practices, disease surveillance capacity, and use of statewide electronic reporting systems. Additionally, IHE websites were searched to identify immunization documentation requirements for matriculating students. Results: Surveys were completed for 33 of 38 eligible IHEs. Twenty-three (70%) IHEs reported that student immunization records are entered into an accessible electronic system or database. Matriculating student immunization requirements were identified for 32 institutions. Of these, 22 (69%) required a physician-signed proof of immunization. No IHEs reported documenting historical immunizations in the statewide electronic immunization system and three IHEs (9%) reported utilizing the state electronic disease surveillance program. Conclusions: Immunization documentation practices vary among IHEs in Indiana and use of statewide immunization and disease reporting systems is minimal. Robust utilization of immunization and disease surveillance systems has been shown to improve public health response to communicable disease outbreaks. Improving mutual understanding of policy and practice between health departments and IHEs could improve the ability to respond to public health challenges.

Background: The Coronary Health Improvement Project (CHIP) is designed to lower cardiovascular risk factors among a group of generally healthy individuals through health education. Purpose: This study will evaluate the efficacy of the CHIP intervention at improving eating, sleep, stress, and depressive disorders. Methods: A health education randomized experimental study was used, with 348 participants, ages 24 to 81 years, from metropolitan Rockford, Illinois. Results: Higher Beck Depression Inventory (BDI) scores at baseline were significantly associated with being overweight, being physically inactive, eating little or no breakfast, eating fast, sleeping less than six hours per night, restless sleep, insomnia, very few vacations, feeling under pressure, being easily emotionally upset, feeling muscular tension, and feeling fearful or depressed. Each of these items showed a significantly greater improvement through six weeks and six months among those in the intervention group compared with the control group. BDI scores through six weeks and six months of follow-up were also significantly lower among those in the intervention group compared with the control group. Discussion: Selected eating and sleep practices were associated with depression. Eating little or no breakfast has been associated with health-compromising behaviors that may increase stress and depression. The health education intervention designed to reduce cardiovascular risk improved eating and sleep practices and reduced stress and depression. Translation to Health Education Practice: Lifestyle change programs such as CHIP aimed at improving physical health behaviors can likewise have a profound influence on mental health. (Contains 3 tables and 1 figure.)

Background: We assessed the effectiveness of a handwashing program using hand sanitizer to prevent school absenteeism due to upper respiratory infections (URIs). Methods: This was a randomized, controlled, and open study on a sample of 1341 children 4-12 years old, attending 5 state schools in Almería (Spain), with an 8-month follow-up. The experimental group (EG) washed their hands with soap and water, together with using hand sanitizer, and the control group followed their usual handwashing procedures. Absenteeism rates due to URIs were compared between the 2 groups through a multivariate Poisson regression analysis. The percent of days missed in both groups were compared with a z test. Results: Overall, 1271 cases of school absenteeism due to URIs were registered. Schoolchildren from the EG had a 38% lower risk of absenteeism due to URIs, incidence rate ratio: 0.62, 95% confidence interval: 0.55-0.70, and a decrease in absenteeism of 0.45 episodes/child/academic year, p < 0.001. Pupils missed 2734 school days due to URIs and the percentage of days absent was significantly lower in the EG, p < 0.001. Conclusions: Use of hand sanitizer plus handwashing with soap accompanied by educational support is an effective measure to reduce absenteeism due to URIs