Transition practice before entering primary school: A longitudinal study of children with and without special needs across a year

IntroductionThe transition to primary school is a significant milestone for children. Transition periods can offer new opportunities to build skills, relationships, and experiences that strengthen self-efficacy. In Singapore, parents play an important role in supporting transition as preschools and primary schools operate independently. Occupational therapists are involved in supporting children with special needs in transitions.ObjectiveFocusing on the transition period of getting children ready for primary school, the objectives are (i) to learn about the strategies that parents used for the purpose of transition and understand the intentions behind what they do and (ii) to compare the transition practices and perceived school readiness between parents of children with and without special needs.MethodA longitudinal study involving 48 parents was conducted over 12 months. Parents completed a survey at the start and end of the year to detect changes from baseline, and semi-structured interviews every two months to gather their subjective experiences and track their child’s readiness for transition. The surveys and interviews were conducted on a mobile instant messaging platform. Coding of responses was guided by school readiness domains identified in earlier studies and Occupational Therapy Practice Framework’s approaches to intervention.ResultsMost parents focused on establishing and maintaining new self-help and academic skills across the year while few were “modifying” or “preventing”. Increasing trends in child readiness were noted for both children with and without special needs.ConclusionIn family-centred practice, it is important to recognise parents’ expertise and resources.     

The Experiences of Family Members of COVID-19 Patients in Iran: A Qualitative Study

BackgroundBeing diagnosed with coronavirus disease-19 (COVID-19) usually causes emotional stress for patients and their families. Understanding the challenges faced by family members of COVID-19 patients is necessary to provide holistic family centered care to support patients and families on their journey to recovery from COVID-19. The aim of this study was to explore the experiences of Iranian family members of COVID-19 patients.MethodsThis qualitative study was performed using the conventional content analysis approach in 2020 in Gorgan, northeastern Iran. Using a purposive sampling 15 family members of inpatient and outpatient COVID-19 patients who were involved in caring of their patients were selected. Data were collected using in-depth and semi-structured interviews and were analyzed by Graneheim and Lundman''s content analysis method with the support of MAXQDA software.ResultsFamily members'' experiences of COVID-19 patients were categorized into two main themes, four category and 10 subcategories. One of the main themes was “psychosocial distress”, with two categories of “uncertainty of the disease” and “perceived psychosocial burdens”. Another main theme was “adaptation strategies”, with the two sub-categories including “adaptative care” and “trusting God”.ConclusionThe results of this study provide a broad range of context-specific challenges faced by family members of Covid-19 patients. It is essential for healthcare providers to be aware of the complex psychological and social conditions of families of Covid-19 patients. Hence, healthcare managers and policymakers should implement preventive and supportive programs at all levels in hospitals and community and provide supportive strategies to reduce or eliminate their challenges.     

Emergency Medical Technicians' Experiences of the Challenges of Prehospital Care Delivery During the COVID-19 Pandemic: A Qualitative Study

BackgroundExploring emergency medical technicians'' (EMTs) experiences of COVID-19 epidemic, help to identify the challenges they face in their daily work and develop strategies that address these challenges. This study aimed to explore EMTs'' experiences of the challenges of prehospital care delivery during the COVID-19 pandemic.MethodsThis qualitative study was conducted in March-July 2020 using conventional content analysis approach. Fifteen EMTs were purposively selected from the Emergency Medical Services (EMS) Center in Qom, Iran. For data collection, semi-structured interviews were conducted until data saturation was reached.ResultsEMTs'' experiences of the challenges of prehospital care delivery during the COVID-19 pandemic were classified into three main categories including “restless society”, “difficult care delivery conditions”, and “unprepared organization”. The emergent subcategories were “need for information”, “limited perception of the COVID-19 risk”, “obsessive use of disinfectants”, “fear over the transmission of COVID-19 to self and others”, “burnout due to heavy workload”, “altered communication with hospital staff”, “ethical conflicts”, “lack of a definite treatment plan”, “lack of protective equipment”, “staff shortage due to the affliction of EMTs by COVID-19”, and “inadequate support by authorities”.ConclusionDuring COVID-19 pandemics, EMTs face many challenges including emotional and occupational stress, social strains, risk of affliction by infections, heavy workload, and ethical conflicts and hence, experience difficulties in quality care delivery. Developing appropriate strategies, guidelines, and policies are needed to effectively manage these challenges and improve the quality of prehospital care delivery in COVID-19 epidemic.     

How Do Mothers Take Care of Their Infants with Colic Pain? A Mixed-Method Study

BackgroundColic pain is one of the main reasons for stress and anxiety in infants'' parents, especially mothers, and there is still no specific treatment. Thus, mothers always try their best to relieve their infants'' pain.The researchers attempted to investigate how mothers take care of their infants with colic.MethodsThis study was conducted with a mixed-method approach and a sequential explanatory design. In the quantitative phase, a cross-sectional study was conducted to assess how to control pain. One hundred fifty mothers of infants with colic living in Kerman, Iran, were chosen by convenience sampling. In the qualitative phase, the researchers interviewed 18 mothers using semi-structured in-depth, and face-to-face approaches. These participants were selected by purposive sampling method. The interviews were analyzed by the conventional content analysis method.ResultsIn the quantitative phase, the mothers'' most common methods to relieve colic pain were herbal medicines (3.55±0.51) and the change of position (3.35±0.67). The least methods used were probiotics (1.4±0.2) and acupuncture (0). In the qualitative phase, the main theme was “mothers support needs for care,” which includes the following subcategories: “lack of trust in doctor”; “full-time care”; “feeling of inadequacy,” “persistent anxiety, “care without help,” and “looking for ways to control pain.”ConclusionMothers need support to relieve their infants'' colic. The provision of educational and psychological supportive packages can be helpful for the mothers. In addition, nurses can help mothers improve their quality of care.     

Trends in Korean parents' perceptions on food additives during the period 2014–2018

BACKGROUND/OBJECTIVESWhile the use of food additives in food processing has become a common practice worldwide, consumers'' worry about potential hazards has not diminished. The purpose of this study was to identify trends in South Korean parents'' perceptions about food additives by analyzing the results of surveys conducted from 2014 to 2018.SUBJECTS/METHODSWe conducted an off-line survey in Korea annually between 2014 and 2018 on perceptions about food additives. The numbers of survey respondents in each year from 2014 to 2018 were 381, 426, 301, 519, and 369, respectively. Our consumer respondents were parents of elementary-school-aged children.RESULTSThe ratios of respondents perceiving “food safety” as the most important factor in purchasing processed foods and “food additives” as the biggest threat to food safety have decreased over the years. However, most consumers still have negative perceptions of food additives. Additionally, among consumers lower confidence in or trust of the Korean government continued throughout the study period and appeared to be the main problem that needs to be overcome.CONCLUSIONSThis study found that Korean parents are still troubled by food additives. Consumers'' confidence in the government needs to be increased through public communications. More multifaceted educational programs communicating scientific knowledge of food additives are needed in order to correct consumers'' misperceptions.     

Root Shock Revisited: Perspectives of Early Head Start Mothers on Community and Policy Environments and Their Effects on Child Health,Development, and School Readiness

Racial differences in school readiness are a form of health disparity. By examining, from the perspective of low-income minority families participating in an Early Head Start study, community and policy environments as they shape and inform lived experiences, we identified several types of social and economic dislocation that undermine the efforts of parents to ready their children for school.The multiple dislocations of community triggered by housing and welfare reform and “urban renewal” are sources of stress for parents and children and affect the health and development of young children. Our findings suggest that racial differences in school readiness result not from race but from poverty and structural racism in American society.

It was more families there. Here it is pretty much individuals. They don''t interact as neighbors. They act as enemies. I don''t have very many friends here. So it''s hard, like, [I can''t ask] “What was it like when your daughter went to kindergarten?” You can''t do that here.—Mother involved in Early Head Start study who was relocated by HOPE VI

SCHOOL READINESS IS AT the heart of current debate on the health and development of young children. Policy discussions focus on the supposed lack of readiness of children in low-income and minority families and on racial and economic “readiness gaps.”¹ In a previous article, we addressed these issues by privileging the voices of low-income, predominantly African American parents to discern meanings of school readiness for them and their efforts to ready their children for school.² What remained unexamined were community and policy influences on school readiness as experienced by study families. In this article, we elaborate on this theme by suggesting new directions in public health research intended to eliminate health disparities.     

Linking Data on Constituent Health with Elected Officials’ Opinions: Associations Between Urban Health Disparities and Mayoral Officials’ Beliefs About Health Disparities in Their Cities

Policy Points

• Mayoral officials’ opinions about the existence and fairness of health disparities in their city are positively associated with the magnitude of income‐based life expectancy disparity in their city.
• Associations between mayoral officials’ opinions about health disparities in their city and the magnitude of life expectancy disparity in their city are not moderated by the social or fiscal ideology of mayoral officials or the ideology of their constituents.
• Highly visible and publicized information about mortality disparities, such as that related to COVID‐19 disparities, has potential to elevate elected officials’ perceptions of the severity of health disparities and influence their opinions about the issue.

ContextA substantive body of research has explored what factors influence elected officials’ opinions about health issues. However, no studies have assessed the potential influence of the health of an elected official''s constituents. We assessed whether the magnitude of income‐based life expectancy disparity within a city was associated with the opinions of that city''s mayoral official (i.e., mayor or deputy mayor) about health disparities in their city.MethodsThe independent variable was the magnitude of income‐based life expectancy disparity in US cities. The magnitude was determined by linking 2010‐2015 estimates of life expectancy and median household income for 8,434 census tracts in 224 cities. The dependent variables were mayoral officials’ opinions from a 2016 survey about the existence and fairness of health disparities in their city (n = 224, response rate 30.3%). Multivariable logistic regression was used to adjust for characteristics of mayoral officials (e.g., ideology) and city characteristics.FindingsIn cities in the highest income‐based life expectancy disparity quartile, 50.0% of mayoral officials “strongly agreed” that health disparities existed and 52.7% believed health disparities were “very unfair.” In comparison, among mayoral officials in cities in the lowest disparity quartile 33.9% “strongly agreed” that health disparities existed and 22.2% believed the disparities were “very unfair.” A 1‐year‐larger income‐based life expectancy disparity in a city was associated with 25% higher odds that the city''s mayoral official would “strongly agree” that health disparities existed (odds ratio [OR] = 1.25; P = .04) and twice the odds that the city''s mayoral official would believe that such disparities were “very unfair” (OR = 2.24; P <.001).ConclusionsMayoral officials’ opinions about health disparities in their jurisdictions are generally aligned with, and potentially influenced by, information about the magnitude of income‐based life expectancy disparities among their constituents.     

How Nurses Apply Patterns of Knowing in Clinical Practice: A Grounded Theory Study

BackgroundNurses require a great deal of knowledge to provide a comprehensive and effective nursing care. A number of patterns have been put into place to help nurses acquire this knowledge. The aim of this study was to describe the core variable in the process of using patterns of knowing by nurses in clinical practice.MethodsThe study was conducted in qualitative and grounded theory approach, between April 2018 and January 2020. Semi-structured interviews were used for data collection. All the interviews were transcribed verbatim. Nineteen clinical nurses were interviewed, and eight observation sessions were conducted in different hospital departments. Participants were first selected through purposeful and then theoretical sampling. Data were analyzed and interpreted using constant comparison analysis approach.ResultsThe findings of the study indicated that nurses apply the patterns of knowing in three ways in their clinical practice: “cohesion of patterns of knowing”, “domination of some patterns of knowing” and “elimination of some patterns of knowing”. The core variable of this process is cohesion of patterns of knowing in the domain of flexibility.ConclusionThe findings of the present study indicate that application of patterns of knowing is practiced in a range of nurse flexibility in clinical settings.     

Come sopravvivere al lavoro monotono e ripetitivo delle Officine Hawthorne: il caso di Geraldina Sirchio (1907-1992) e le altre ragazze immigrate della test room

«Surviving monotony and repetitiveness at Hawthorne Works: the case of Geraldina “Jennie” Sirchio (1907-1992) and the other migrant girls in the test-room»Background:The research studies in the test room (t-room) at the Hawthorne Works still represent a «mythical» experiment, the most important one. In 1928 the experiment took flight with the Italian Geraldina Sirchio.Objectives:Reporting the living and working conditions of Geraldina and young migrants.Methods:The 22 interviews with Geraldina (1931-1932) conducted by Igemon Rousseau were acquired from Cornell University. The original video of the work in the t-room was analyzed with the method of organizational congruencies.Results:Geraldina left school to work at the age of 14. At 21 she was asked to work in the t-room. She was the fastest girl, unmarried and the “breadwinner” of her family. She was petite, smart and emancipated. Working conditions in the t-room were less challenging than in the “big department” and Geraldina defended them by guaranteeing continuity and very high productivity. In the interviews, she often reported constraints such as low wages, high speed, short breaks, back pain, heat, swollen feet, weight loss and the fainting of girls for “heat prostration”. The interviewer always attributed Geraldina work-related problems to her housework duties. In June 1932, during the last interview, Geraldina expressed her anger for the layoffs, particularly on behalf of the other Italian Antoinette Parillo and the Polish Theresa Layman, both fired despite having to support families with numerous children. She herself was fired five months later.Conclusions:The “Geraldina’s effect” is discussed through her own words offering a truthful picture of the migrant working conditions during the Great Depression.Key words: Jennie Sirchio, Hawthorne, risks, migrants, interviews     

Relative Importance of Determinants of Changes in Eating Behavior during the Transition to Parenthood: Priorities for Future Research and Interventions

Background: Healthy eating behavior throughout pregnancy and postpartum is important. This study aimed to investigate the perceived sex-specific importance of determinants of changes in eating behavior during pregnancy and postpartum. Methods: Fifty-four determinants were rated by first-time parents (n = 179) on their impact. Experts (n = 31) rated the determinants in terms of their modifiability, relationship strength, and population-level effect from which a “priority for research”-score was calculated. Results: During pregnancy, the three highest rated determinants by women were “health concerns”, “physiological changes”, and “fatigue”. Men perceived “health concerns”, “health consciousness”, and “influence of the pregnant partner” as important. Postpartum, the three highest rated determinants by women were “adaptation to rhythm of baby”, “baby becomes priority”, and “practical constraints because of the baby”. Men perceived “adaptation to rhythm of baby”, “fatigue”. and “(lack of) anticipation” as important. According to the experts, “professional influence”, “food knowledge”, and “home food availability” received high priority scores for both sexes and during both periods. Conclusions: Priority for research and interventions should go towards tailored family-based approaches focusing on food education in a broad sense taking into account aspects such as health consciousness, self-efficacy skills, and the social and home food environment while being supported by healthcare professionals.     

Feeling confident in burdensome yet enriching care: Community nurses describe the care of patients with hard-to-heal wounds

Treating patients with hard-to-heal wounds is a complex task that requires a holistic view. Therefore this study focuses on the nurse''s perspective with the aim on describing how community nurses experience the phenomenon the care of patients with hard-to-heal wounds. The method used was a reflective lifeworld approach. Seven qualitative interviews with community nurses were conducted. The findings show a tension between enriching and burdensome care. In this tension, the nurses try to find energy to reach harmony in their work through reflection, acceptance, and distance. This is further described by the constituents: “taking responsibility,” “showing respect for the whole person,” “being confident in order to offer confidence,” “seeing time and place as important.” The discussion highlights the importance for a nurse to find how to give ideal care in one''s duty but not beyond it. As a consequence the concept “compliance” needs to be challenged in order to promote confidence and mutual trust between nurses and patients. Confidence can be seen as a key, both for nurses and patients, and is dependent on good inter-professional cooperation, competence, and closure.     

Prenatal and Postnatal Tobacco Exposure and Behavioral Problems in 10-Year-Old Children: Results from the GINI-plus Prospective Birth Cohort Study

Background

Prenatal and postnatal tobacco exposure have been reported to be associated with behavioral problems. However, the magnitude of the association with tobacco exposure at specific periods of exposure is unclear.

Objective

We assessed the relative risk of behavioral problems in children who had been exposed to tobacco smoke in utero and postnatally.

Methods

We analyzed data from a prospective birth cohort study in two cities in Germany: the German Infant Nutrition Intervention. Our sample included 5,991 children born between 1995 and 1998 as well as their parents. We measured behavioral problems using the Strength and Difficulties Questionnaire (SDQ) at follow-up 10 years after birth. According to prespecified SDQ cutoff values, children were classified as “normal,” “borderline,” or “abnormal” according to the subscales “emotional symptoms,” “conduct problems,” “hyperactivity/inattention,” “peer-relationship problems,” and a total difficulties score. Smoke exposure and further covariates were assessed using parent questionnaires.

Results

Compared with children not exposed to tobacco smoke, children exposed both pre- and postnatally to tobacco smoke had twice the estimated risk [95% confidence interval (CI), 1.4–3.1] of being classified as abnormal according to the total difficulties score of the SDQ at 10 years of age. Children who were only prenatally exposed had a 90% higher relative risk (95% CI, 0.9–4.0), whereas children who were only postnatally exposed had a 30% higher relative risk (95% CI, 0.9–1.9). These results could not be explained by confounding by parental education, father’s employment, child’s time spent in front of computer or television screen, being a single father or mother, or mother’s age.

Conclusions

Prenatal exposure to tobacco smoke is associated with behavioral problems in school-age children. Although our findings do not preclude the influence of postnatal exposure, prenatal exposure seems to be more important.     

Community factors to promote parents’ quality of child-nurturing life

ObjectivesThe purpose of this study was to clarify the role of community factors in parents’ quality of child-nurturing life (QCNL).MethodsWe developed a questionnaire to evaluate the degree of QCNL and determine the structural factors related to QCNL as community factors related to parents’ QCNL derived from focus group interviews and the Delphi technique. The questionnaire also included the battery of the self-rating depression scale and Tsumori-Inage Infant''s Developmental Test. Using the questionnaire, we then conducted a quantitative survey of parents whose children attended nursery schools in Kumamoto Prefecture. Factor analysis, calculation of the mean score and/or ratio to each item, Pearson’s correlation coefficient, t test, multiple regression analysis, and covariance structure analysis were performed.ResultsThe questionnaire we developed consisted of seven items with 75 elements, involving ten elements as community factors. Subjects included 699 parents (mean age 33.6 ± 5.4 years) and 965 children (age range 0–6 years). Factor analysis revealed that community factors consisted of five factors, such as “lifestyle rooted in the ground,” “balance of housekeeping and work,” “community network,” “amenity,” and “regeneration of life”. These factors may be dominant in a rural area. Finally, we developed a structural model with “community factors,” QCNL, QOL, and “child growth” by covariance structural analysis. The analysis revealed that community factors had a positive relation to parents’ QCNL (r = 0.81, p < 0.001) and that parental SDS score had a negative relation to parents’ QCNL (r = −0.59, p < 0.001). The analysis did show that community factors were positively related to the sound growth of children.ConclusionThe covariance structure analysis revealed that community factors were associated with parents’ QCNL, SDS, and “child growth.”     

COVID-19 Vaccine Perception in South Korea: Web Crawling Approach

BackgroundThe US Centers for Disease Control and Prevention and the World Health Organization emphasized vaccination against COVID-19 because physical distancing proved inadequate to mitigate death, illness, and massive economic loss.ObjectiveThis study aimed to investigate Korean citizens’ perceptions of vaccines by examining their views on COVID-19 vaccines, their positive and negative perceptions of each vaccine, and ways to enhance policies to increase vaccine acceptance.MethodsThis cross-sectional study analyzed posts on NAVER and Instagram to examine Korean citizens’ perception of COVID-19 vaccines. The keywords searched were “vaccine,” “AstraZeneca,” and “Pfizer.” In total 8100 posts in NAVER and 5291 posts in Instagram were sampled through web crawling. Morphology analysis was performed, overlapping or meaningless words were removed, sentiment analysis was implemented, and 3 public health professionals reviewed the results.ResultsThe findings revealed a negative perception of COVID-19 vaccines; of the words crawled, the proportion of negative words for AstraZeneca was 71.0% (476/670) and for Pfizer was 56.3% (498/885). Among words crawled with “vaccine,” “good” ranked first, with a frequency of 13.43% (312/2323). Meanwhile, “side effect” ranked highest, with a frequency of 29.2% (163/559) for “AstraZeneca,” but 0.6% (4/673) for “Pfizer.” With “vaccine,” positive words were more frequently used, whereas with “AstraZeneca” and “Pfizer” negative words were prevalent.ConclusionsThere is a negative perception of AstraZeneca and Pfizer vaccines in Korea, with 1 in 4 people refusing vaccination. To address this, accurate information needs to be shared about vaccines including AstraZeneca, and the experiences of those vaccinated. Furthermore, government communication about risk management is required to increase the AstraZeneca vaccination rate for herd immunity before the vaccine expires.     

Cancer Research Center Hotline: “Sun Safe Kids,” Implementing a Low Cost,School-based Public Policy to Protect Hawai‘i's Children from Skin Cancer Risks

The rates of melanomas and skin cancers are increasing in the United States. Children attending elementary schools are in the most danger of acquiring these diseases later in life, and elementary school children in Hawai‘i have the greatest risk of all children in the United States. The parents and educators of Hawai‘i''s elementary school age children are unaware of the potential risks for cancer that young children experience every day at school. Effective sun protection policies have been implemented in other jurisdictions, including Australia, that have similar risks for over-exposure to solar ultraviolet radiation in children. These proven policy models can inform sun protection practices in Hawai‘i. A simple policy whereby public elementary schools require that children wear ordinary long sleeves shirts and hats during the school''s outdoor activities will protect Hawai‘i''s children from overexposure to sun''s ultraviolet radiation. Establishment of a state law codifying the implementation of this simple, yet scientifically proven strategy into the policies of Hawai‘i''s public elementary schools can significantly reduce the incidence and deaths from melanoma and skin cancer in the state.The rates of melanomas and skin cancers are increasing in the United States.^1,2 Children attending elementary schools are in the most danger of acquiring these diseases later in life, and elementary school children in Hawai‘i have the greatest risk of all children in the United States.^3,4 The parents and educators of Hawai‘i''s elementary school age children are unaware of the potential risks for cancer that young children experience every day at school.⁴ Public elementary schools can simply require that elementary school age children wear ordinary long sleeves shirts and hats during the school''s outdoor activities, applying a “No Hat, No Shirt, No Play” school uniform requirement policy, to protect these children from overexposure to sun''s ultraviolet radiation.^3–5 Establishment of a state law codifying the implementation of this simple, yet scientifically proven strategy into the policies of all of Hawai‘i''s public elementary schools can significantly reduce the incidence and deaths from melanoma and skin cancer in the state.Skin cancers are the most preventable type of cancer.^4,6 Over the past 10 years, the number of deaths from most other types of cancer in the United States, and Hawai‘i have dropped significantly.⁷ A large portion of this reduction in cancer death rates is attributed to improved primary prevention practices.⁸ However, despite improvements in the management of other cancer types, the incidence and death rates from melanoma and skin cancers continue to rise at an alarming rate.⁹ There were an estimated 1.4 million new cases of skin cancer diagnosed in the United States, in 2008, accounting for nearly half of all cancer incidence.¹⁰ In Hawai‘i, it is estimated that over 5,000 people will be diagnosed and treated for skin cancer this year.⁷ The depletion of the earth''s ozone layer, that provides our planet with protection against solar UV radiation, is a major factor contributing to the increasing rates of skin cancer.¹¹ Hawai‘i''s proximity to the equator where the sun rays are more direct, add to this enhanced risk of skin cancer for the local residents and visitors.⁴ Efforts to reduce exposure to ultraviolet radiation, particularly in Hawai‘i will reduce the burden of this disease.There are two types of skin cancers, non-melanoma skin cancers, and melanomas. Both are attributable to overexposure to UV radiation, particularly during childhood.⁵ Fifty to 80% of a person''s lifetime cumulative exposures to the sun''s UV radiation occur before age 18.⁴ Non-melanoma skin cancers, called basal and squamous cell skin cancers occur in the surface layers of the skin. Although these types of skin cancers are often not fatal, they do account for significant morbidity and malaise associated with the excision of a patients'' sun exposed areas, including the skin of the hands, legs, neck, and face.¹⁰ Children who experience severe blistering sunburns are at increased risk for melanomas.⁹ Melanomas arise in the skin pigmentation cells, presenting common risks for melanomas in people with dark completions as those with lighter completions.⁴ Melanomas are a less common skin cancer type but they are the most deadly type, accounting for 75% of all deaths related to skin cancer.⁴ Parents are legally and morally responsible for the safety and welfare of their young children. Public school teachers, school administrators, and by extension the state governments who manage, fund, and establish policies for public schools, assume this parental responsibility while children attend. In Hawai‘i, 97% of children, ages 3 to 14, or about 179,475 students attend elementary schools, and 63% of these students attend public elementary schools in the state.¹² In Hawai‘i''s tropical climate, schools are traditionally built with open architectural features and campus layouts to facilitate natural structural cooling by mountain trade winds.⁴ These design features of Hawai‘i''s schools expose students to direct sunlight while walking between class, during physical education athletic activities, during recesses, and during lunch periods while at school.⁴ Hawai‘i''s parents and educators unwittingly expose young children to dangerous levels of UV radiation while at school, and establish schools as a primary risk setting for the development of skin cancer in adults. The use of sun protection strategies in elementary school children is estimated to have the potential to reduce the risk of developing skin cancer by 78%.⁴Educators in both the United States and Hawai‘i are receptive and willing to implement sun protection policies for primary school children when the risks are made clear to the school administrators, faculty, and teachers. A study conducted by Buller et al (2002) was designed to assess sun protection policies in the United States. The researchers surveyed 1000 public elementary schools. The study found that only 3.4% of the schools had sun protection policies for children, although 84% reported that the students were outdoors during peak periods of the day for UV exposures.¹³ Most of the administrators, about 72.8%, were willing to adopt sun exposure mitigation policies; however the majorreported barriers were lack of awareness of the risks and organizational barriers in school districts.¹³ A similar study conducted in Hawai‘i by Eakin, et al (2004) found that 99% of the schools in Hawai‘i scheduled outdoors activities during the midday peak UV radiation, and that few schools had sun protection uniform policies.⁴ Among the primary school educators surveyed in Hawai‘i, 78% believed that excessive sun exposure was an important childhood risk for skin cancers, and over a third were in favor of a statewide policy to prevent skin cancer risks in their children.⁴In the US Center for Disease Control and Prevention''s “Guide to Community Preventive Services” (a compendium of all the empirically tested research on methods to reduce the burden of common diseases in the United States), there are only two interventions recommended to be proven effective methods to prevent skin cancers and melanomas in young people.¹⁴ The first method is the promotion of covering up behavior, including wearing long-sleeved clothing and hats. The second is providing policy changes and education in elementary school settings.¹⁴ These two specific interventions by the CDC are the result of the agency''s systematic review of over 159 studies, considering interventions'' scientific merit, barriers to implementation, overall costs, and cost effectiveness. Several types of prevention strategies were rigorously evaluated to identify the best population-based skin cancer prevention programs. A “No Hat, No Shirt, No Play” policy was recommended as the intervention strategy for primary schools.The CDC examined studies using various types of interventions, including the development and promotion of public media education campaigns about risk, promoting the use of sunscreen, and enhancing access to and utilization of clinical and self-administered skin cancer screenings. These methods were not found to be as effective, efficacious, or cost-effective as simply having primary school children wear a hat and long sleeves during participation in outdoor activities at school.¹⁴ The development of a “No Hat, No Shirt, No Play” policy in Hawai‘i''s public schools offers the application of the best science to prevent skin cancer, and is proven to be an acceptable prevention method for children, their parents, and educators.³There are several examples of school-based policies that have been adopted that can be used as a model to create state legislation designed to curb the epidemic rise in skin cancer rates in Hawai‘i. In Australia, a country that shares similar proximity to the earth''s equator as Hawai‘i, the implementation of a “No Hat, No Shirt, No Play” school policy was evaluated in a study entitled “Kidskin.”⁵ This randomized and controlled community trial utilized objective observational assessments of adherence to a “No Hat, No Shirt, No Play” policy by primary school children, parents, and educators in a range of primary schools in Australia.⁵ The researchers found that even in schools that did not receive the complementary education program about sun protection behaviors and strategies, there was a 76% adherence to the “No Hat, No Shirt, No Play” policy by the school children. Also described in the “Kidskin” research, the intervention schools, where a full complement of sun protection education was delivered, the students, the parents, and school educators'' adherence rates to the “No Hat, No Shirt, No Play” policy ranged from 85% to 100%. These adherence measures were obtained during unannounced videotaping of these primary school students during their outdoor, lunch, and recess activities. No other skin cancer prevention policy measures implemented by the “Kid-skin” program in Australian schools, including the establishment of increased shade structures in the children''s outdoor play areas, matched the effectiveness of the children and the schools in the “No Hat, No Shirt, No Play” policy.⁵Despite the overwhelming adherence of Australian children to Kidskin''s “No Hat, No Shirt, No Play” policy, there were barriers to implementation. These barriers may represent a challenge to Hawai‘i state legislation for a statewide “No Hat, No Shirt, No Play” policy in Hawai‘i''s schools. In the Kidskin study, parental support to enforce their children''s wearing of the program''s recommended “Gold Standard” hat was challenging. The researchers hypothesize that additional parental education may reduce the effect of this parental barrier to the policy.⁵ This barrier also underscores the importance of the additional inclusion of adult education about the risks of sun protection in children, combined with the mandatory “No Hat, No Shirt, No Play” policy. These two components can serve to reinforce the adherence to the program.It is not clear from the Kidskin study whether clothing costs were also a factor associated with preventing parent''s adoption of the “No Hat, No Shirt, No Play” policy. There will be always be parents who are not financially able to meet the “No Hat, No Shirt, No Play” policy program''s requirement to provide a long sleeve shirt and hat for their child. A support program for parents who are unable to provide these apparel resources could be established, and based upon parental income eligibility requirements. Income data from the Hawai‘i Department of Business Economic Development and Tourism can be used to determine the cost of such a program. It is estimated that there are about 13% of individuals with children under the age of 18, or about 38,000 people who have incomes that are below state poverty levels.¹⁵ Applying this data, it is estimated that approximately 5,000 children in Hawai‘i would need financial support to meet the requirements of a statewide “No Hat, No Shirt, No Play” policy program.¹⁵The adoption of a support program for low income families to adhere to a Hawai‘i primary school “No Hat, No Shirt, No Play” policy may not require the use of any public funding. As part of the state''s, “No Hat, No Shirt, No Play” policy program, an information list of preferred hat and long sleeve shirt vendors could be included as a resource for parents to obtain the suitable clothing needed to meet the program''s requirements. Clothing vendors, as a benefit for being placed on this vendor resource list, would agree to donate 10% of their expected sales profits in merchandise, and this merchandise would in turn be made available to parents who are unable to meet the “No Hat, No Shirt, No Play” policy program''s uniform requirement for their children.It is expected that the increased vendor sales revenue realized by requiring parents to include a long sleeve shirt and hat as part of a outdoor school uniform would generate about 3.8 million dollars in new spending if only 85% of the 96,108 public school primary students and their parents adhere to the program by buying shirts and hats at the retail price which will cost about $40.00 (Deputla, personal communication, 2009). Shirt and hat clothing vendors typically make a minimum of about $2 to $4 in profit per item (Deputla, personal communication, 2009). Adding a 10% allocation from vendors would generate about $40,000 in funds towards the support of the expected 5,000 families needing help. This allocation could still provide the vendors with a minimum of $345,988 in annual net profits to share.There are additional challenges to the implementation of a “No Hat, No Shirt, No Play” policy in Hawai‘i primary schools. The implementation of this policy, and the requirements for adherence, could dissuade public schools from promoting outdoor activities and seriously curb support of the state''s primary schools already tenuous budgets for athletic programs. The reality of reducing support for primary school physical activity for students could also contribute to the increasing obesity rates in young people.³ To minimize the potential for the “No Hat, No Shirt, No Play” policy to reduce physical activity in schools, the program can incorporate the use of policy champions. Policy champions could be comprised of prominent athletic figures in Hawai‘i''s culture, including use of University of Hawai‘i sport figures or other well-known local athletes. These champions would serve to extol the benefits of physical activity while simultaneously modeling use of the sun protection apparel used in conjunction with the “No Hat, No Shirt, No Play” policy for schools. Adding the use of these athletic figures or champions is a program component suggested by the Kidskin researchers, and could be part of the program''s educational campaign for schools administrators, parents, and students.⁵There is a perceived concern by the public, promoted through popular media about the potential for skin cancer prevention strategies to cause a reduced absorption of vitamin D in primary school children, a primary metabolic process enhanced through exposure to sunlight. Researchers in Australia noted that there were public misconceptions arising from these media reports about the benefits of sunlight exposure for the enhancement of natural absorption of vitamin D.¹⁶ Australia''s media reports about vitamin D served to reduce adherence to the established sun protection programs and policies recently developed in this country. This effect was significant despite the lack of empirical evidence that sun prevention activities presented little risk of vitamin D deficiencies in populations.⁸ Current research is now being conducted to clarify the role of vitamin D absorption, and identify if there is a relationship between vitamin D consumption and cancer prevention.⁸ However, until definitive conclusions are made about the possible harm presented by reduced vitamin D absorption caused by skin cancer prevention programs, there remains a consistent and clear link between skin cancer including melanomas and overexposure to the sun in children.¹⁶ Additionally in the United States most milk and other food products in the United States provide sufficient supplementation of vitamin D for children and adults.⁸ The mixed messages about vitamin D deficiencies and sun exposure prevention remain inaccurate and unfounded.Beyond the subsequent suffering and death in adulthood that will result from failure to implement primary skin cancer prevention policies, there is a great potential for these diseases to present a tremendous and avoidable financial load on Hawai‘i''s healthcare systems. In 1997, the annual cost of treating the estimated 40,000 melanoma cases in the United States was about 567 million dollars, or an average of about $14,000 per patient per year.¹⁷ However, the annual costs per patient are disproportionately spread among the range of patients, with the cost being $1,310 for patients who are diagnosed with early stage disease, versus $42,000 for patients with later stage cancers.¹⁷ These costs do not include indirect costs, incorporating the loss of earnings and other expenses associated with the disease.The total financial burden of melanoma in the United States is estimated at 1 billion dollars annually.¹⁷ Additionally, these are the costs estimated for the least common type of skin cancer, melanoma. Consider this, cost estimates can be made to include the more common basal and squamous cell skin cancers, and use a treatmentcost model comprised of only excision ($275/pt/yr). Applying this minimum per-person medical cost to the 1.35 million expected new basal and squamous skin cancer cases in the United States, and the 4, 950 expected new cases in Hawai‘i, the annual skin cancer treatment costs amount to nearly $39 billion for the United States, and $1,475,000 for Hawai‘i using 1997 dollars. Finally, the incidence of skin cancers and melanomas becomes more prevalent and frequent after age 50, so that this preventable medical and financial burden will most likely be supported through government Medicare disbursements for people who are older.¹⁰There are models of effective sun protection policies that have been successfully adopted in Hawai‘i''s private primary schools. Research conducted by a Hawai‘i dermatologist, Dr. Nip-Sakamoto at Punahou and Iolani Schools in 2000, pilot tested the efficacy of sun protection education for students, educators, and parents, combined with school policies requiring primary school children to wear sun protection gear including hats (Nip-Sakamoto, personal communication, 2009). Currently, nine years after the initial pilot projects were completed in these schools, both Punahou and Iolani School have instituted broad skin cancer prevention policies that include use of sun protection clothing, education for students, faculty, and parents, and also the new construction and use of sun protective structures in their outdoor sports and recreational facilities (Nip-Sackmoto, personal communication, 2009).Finally, in Hawai‘i there are models for the legislation that support a requirement for parents to provide disease prevention interventions for their children. Since 2002, State Department of Health''s Administrative Rules support legislation for the “Vax-to-School” program that has successfully demonstrated use of a statewide policy to encourage health promotion in primary school students.¹⁸ The program requires that primary school children, and children in other age groups be administered vaccines for many common diseases including chicken pox, rubella, measles, mumps, hepatitis B, diphtheria, tetanus, and pertussis.¹⁹ This program has supported the vaccination of primary school children through the use of over 260 medical providers. The CDC estimates that the program supports Hawai‘i''s 90% immunization rate for children entering elementary schools.²⁰ Funding for the program is provided by allocations from the CDC, in conjunction with the Hawai‘i State Medicaid program.^19,20 The programmatic policy standards of the “Vax to School” program can be successfully adapted for “No Hat, No Shirt, No Play” legislation.Although there are several barriers that can contribute to the implementation of a mandated statewide “No Hat, No Shirt, No Play” policy for primary school children, there is overwhelming evidence that this type of intervention may be a feasible and an effective method to promote the health and safety of our children. The potential costs of not implementing this simple strategy can be considered using various measures including the potential treatment cost for skin cancer, the personal disfigurements created by these treatments, or the number of deaths that will eventually result from overexposure to the sun. Currently there are few options to prevent cancers. There has been great success in changing social norms concerning tobacco use in young people, subsequently reducing mortality rates from this disease. Overexposure to the sun represents the new paradigm in cancer prevention for our children. We can implement changes now that can assure our children a more healthy future.     

Mental Illness Disclosure in the Workplace: An Opportunity for Improvement

BackgroundThe Americans with Disabilities Act (ADA) prohibits discrimination based on physical or mental disabilities and requires that employers provide reasonable accommodations to workers with disabilities who can perform their essential job functions. However, the ADA also states that an employer is not required to hire or keep an individual with a psychiatric disability if it poses a direct threat to his or her safety or the safety of others.ObjectivesTo identify employers'' disclosure requirements for mental illness diagnosis or treatment during the job application process and/or as a condition of ongoing employment, to determine disclosure requirements of state and federal licensing bodies, and to evaluate the legality of disclosure of mental health status.MethodsWe conducted an Internet-based search to identify public and private employers'' disclosure requirements based on 4 keyword combinations, including “employment/mental health,” “employment/mental illness,” “license application/mental illness,” and “license application/mental health.” Other employers were included based on known federal and/or state certification requirements or a governing body policy for employee suitability and fitness. A panel of 3 investigators reviewed the data and analyzed the key findings, industry trends, and workplace implications.ResultsOf the 23 industries (eg, construction, government, military, transportation) investigated, 5 were public and 18 were private. Public employees and government-regulated companies often required disclosure of mental health conditions because of the nature of the work. Private companies showed more variability than public in whether applications contained disclosure requirements, some of which were not compliant with the ADA regulations.ConclusionAcross the United States, job applicants and workers are often asked to disclose mental health status as a condition of employment. Consequently, applicants and workers may hide mental health issues, resulting in the underuse of mental health resources by those in need.     

Gender Difference in the Association Between E-Cigarette Use and Depression among US Adults

ObjectivesThe objective of this study was to determine the association between e-cigarette use and depression and examine how this association is different by gender among US adults.MethodsData from the 2017 Behavioral Risk Factor Surveillance System and Selected Metropolitan/Micropolitan Area Risk Trends was used, and included 174,351 of 230,875 US adults aged 18 years and older. Data were analyzed using the multivariate logistic regression models.ResultsAfter adjusting for age, race, education, income, marital status, employment status, smoking status, and physical activity, firstly, “current daily e-cigarette users” (AOR = 2.487, p < 0.001), “current non-daily e-cigarette users” (AOR = 1.623, p < 0.001), and “former e-cigarette users” (AOR = 1.573, p < 0.001) were associated with increased odds of depression compared with “never e-cigarette users.” Secondly, women were associated with increased odds of depression compared with men (AOR = 1.797, p < 0.001). Finally, male “current daily e-cigarette users” (AOR = 1.366, p < 0.01) were associated with increased odds of depression compared with female “never e-cigarette users.”ConclusionThus, even though women tend to be more vulnerable to depression compared with men, e-cigarette use was positively associated with depression among both men and women.     

Evaluation of dietary behaviors of preschool children in Seoul and Gyeonggi-do associated with the level of parents' health consciousness: using nutrition quotient for preschoolers (NQ-P)

BACKGROUND/OBJECTIVESThis study aimed to assess the dietary behaviors of preschool children using the nutrition quotient for preschoolers (NQ-P) and analyzed the difference in the scores of the children''s dietary behaviors in regards to the parents'' health consciousness.SUBJECTS/METHODSThe subjects were 257 children aged 3–5 years and their parents residing in Seoul and Gyeonggi-do, South Korea. The questionnaire is composed of demographic characteristics, the NQ-P questions, and health consciousness. All data were statistically analyzed by SPSS program (ver. 25.0) and the statistical differences in variables were evaluated by χ² test, Fisher''s exact test, t-test, 1-way analysis of variance and Tukey''s multiple comparison test.RESULTSThere was a significant difference on the intake frequency of processed meat by region and fast foods by age, region, and weight status (P < 0.05). There was also a significant difference in not moving around while eating by weight status and parents'' effort to have healthy eating habits by sex (P < 0.05). The mean score of NQ-P of the total subjects was 59.47, which was within the medium-low grade. The mean score of balance was 61.62, and the boys were significantly higher than girls (P < 0.05). As the age of children increased, the mean score of the moderation was significantly decreased (P < 0.05). The scores of NQ-P (P < 0.05), balance (P < 0.01), and environment (P < 0.05) were significantly higher in the high group of parents'' health consciousness than the low group.CONCLUSIONSAccording to the results of the evaluation by NQ-P, the dietary behaviors of preschoolers residing in Seoul and Gyeonggi-do need to be improved. For improving their eating behavior and nutritional health status, parents and children need customized nutrition education programs based on sex, age, region and weight status of preschool children as well as the degree of parents'' health consciousness.     

Joy without demands: Hospital clowns in the world of ailing children

The aim of the present study was to achieve, using an affect theory approach (Tomkins, 1962; 1963; 1991), a deeper theoretical understanding of the psychological significance of hospital clowns'' work in caring for ailing children viewed from a care-giver perspective. The methodological approach was qualitative and based on 20 interviews with healthcare staff: 3 men and 17 women. The result showed how the staff emphasized a psychological quality of care alongside the physical quality of care. The hospital clowns'' “unexpected possibility” provided a safe area for recovery, for both the children and the staff. The theoretical interpretation showed the presence of the affects surprise/startle, interest/excitement, and enjoyment/joy as well as specifically how “joy without demands” often had a lingering effect in the form of vitality. Joy without demands is discussed in relation to psychological theory with emphasis on: a confirmation of the body''s possibilities, a magical attachment, a chance to transcend boundaries, and a non-demanding situation.