Clinical Focus

  • Pediatrics

Academic Appointments

Administrative Appointments

  • Co-Director, Center for Policy, Outcomes and Prevention (2013 - Present)
  • Co-Director, Fellowship in Academic General Pediatrics (2012 - Present)
  • Chief, Division of General Pediatrics (2014 - Present)

Boards, Advisory Committees, Professional Organizations

  • Council Member, Society for Pediatric Research (2011 - Present)

Professional Education

  • Residency:Stanford Medicine General Surgery ResidencyCA
  • Internship:Stanford Medicine General Surgery ResidencyCA
  • Board Certification: Pediatrics, American Board of Pediatrics (1998)
  • Medical Education:Stanford University School of Medicine (1994) CA

Research & Scholarship

Current Research and Scholarly Interests

As a general pediatrician with a joint appointment in the Center for Health Policy and Primary Care Outcomes Research, my research focuses on the field of health literacy. Informed by social cognitive theory, I conduct interdisciplinary research to understand child and parent health literacy as potentially modifiable determinants of child health disparities. I am principal investigator on an NICHD-funded, multi-site, randomized controlled trial to assess the efficacy of a low-literacy, early-childhood intervention designed to prevent obesity in the first two years of life. I recently completed a community-based, participatory research study to examine the effectiveness of child health promotion delivered across a large network of early child-care centers in underserved communities ( The aim of my current scholarship is to apply the health-literacy model to attenuate disparities for children with chronic illness and special health care needs.

My work is informed by a public-health perspective and by delivering front-line care in underserved communities. Between 2006 and 2011, I served as Medical Director of Children’s Medical Services South Florida, a Florida state agency that coordinates care for more than 10,000 low-income children with special health care needs. I founded Stanford's Reach Out and Read program, and for ten years served as Medical Director for Reach Out and Read Florida, a pediatric-clinic-based program that provides books and early-literacy promotion to more than 200,000 underserved children. Prior to joining the Stanord faculty, I co-directed the Jay Weiss Center for Social Medicine and Health Equity, which fosters a scholarly community committed to addressing global health inequities through community-based participatory research. I have served as an advisor to the Institute of Medicine, the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the Academic Pediatric Association, and the American Cancer Society. Fluent in Spanish, I maintain an active general pediatrics practice, serving an socioeconomically disadvantaged population of patients, with a focus on behavioral health, obesity prevention, post-NICU care of premature infants, and the care of complex chronic conditions.

Clinical Trials

  • Addressing Health Literacy and Numeracy to Prevent Childhood Obesity Not Recruiting

    In 2003, Surgeon General Richard Carmona suggested that low health literacy is "one of the largest contributors to our nation's epidemic of overweight and obesity." Over 26% of preschool children are now overweight or obese, and children who are overweight by age 24 months are five times as likely as non-overweight children to become overweight adolescents. The aim of the study is to assess the efficacy of a low-literacy/numeracy-oriented intervention aimed at teaching pediatric resident physicians to promote healthy family lifestyles and prevent overweight among young children (age 0-2) and their families in under-resourced communities.

    Stanford is currently not accepting patients for this trial.

    View full details


2017-18 Courses

Stanford Advisees


All Publications

  • Inpatient Hospital Factors and Resident Time With Patients and Families PEDIATRICS Destino, L. A., Valentine, M., Sheikhi, F. H., Starmer, A. J., Landrigan, C. P., Sanders, L. 2017; 139 (5)


    To define hospital factors associated with proportion of time spent by pediatric residents in direct patient care.We assessed 6222 hours of time-motion observations from a representative sample of 483 pediatric-resident physicians delivering inpatient care across 9 pediatric institutions. The primary outcome was percentage of direct patient care time (DPCT) during a single observation session (710 sessions). We used one-way analysis of variance to assess a significant difference in the mean percentage of DPCT between hospitals. We used the intraclass correlation coefficient analysis to determine within- versus between-hospital variations. We compared hospital characteristics of observation sessions with ≥12% DPCT to characteristics of sessions with <12% DPCT (12% is the DPCT in recent resident trainee time-motion studies). We conducted mixed-effects regression analysis to allow for clustering of sessions within hospitals and accounted for correlation of responses across hospital.Mean proportion of physician DPCT was 13.2% (SD = 8.6; range, 0.2%-49.5%). DPCT was significantly different between hospitals (P < .001). The intraclass correlation coefficient was 0.25, indicating more within-hospital than between-hospital variation. Observation sessions with ≥12% DPCT were more likely to occur at hospitals with Magnet designation (odds ratio [OR] = 3.45, P = .006), lower medical complexity (OR = 2.57, P = .04), and higher patient-to-trainee ratios (OR = 2.48, P = .05).On average, trainees spend <8 minutes per hour in DPCT. Variation exists in DPCT between hospitals. A less complex case mix, increased patient volume, and Magnet designation were independently associated with increased DPCT.

    View details for DOI 10.1542/peds.2016-3011

    View details for Web of Science ID 000400371500022

    View details for PubMedID 28557735

  • Liquid Medication Dosing Errors by Hispanic Parents: Role of Health Literacy and English Proficiency ACADEMIC PEDIATRICS Harris, L. M., Dreyer, B. P., Mendelsohn, A. L., Bailey, S. C., Sanders, L. M., Wolf, M. S., Parker, R. M., Patel, D. A., Kim, K. Y., Jimenez, J. J., Jacobson, K., Smith, M., Yin, S. 2017; 17 (4): 403-410


    Hispanic parents in the United States are disproportionately affected by low health literacy and limited English proficiency (LEP). We examined associations between health literacy, LEP, and liquid medication dosing errors in Hispanic parents.Cross-sectional analysis of data from a multisite randomized controlled experiment to identify best practices for the labeling/dosing of pediatric liquid medications (SAFE Rx for Kids study); 3 urban pediatric clinics. Analyses were limited to Hispanic parents of children aged ≤8 years with health literacy and LEP data (n = 1126). Parents were randomized to 1 of 5 groups that varied by pairing of units of measurement on the label/dosing tool. Each parent measured 9 doses (3 amounts [2.5, 5, 7.5 mL] using 3 tools [2 syringes in 0.2 or 0.5 mL increments, and 1 cup]) in random order. Dependent variable was a dosing error of >20% dose deviation. Predictor variables included health literacy (Newest Vital Sign) (limited = 0-3; adequate = 4-6) and LEP (speaks English less than "very well").A total of 83.1% made dosing errors (mean [SD] errors per parent = 2.2 [1.9]). Parents with limited health literacy and LEP had the greatest odds of making a dosing error compared to parents with adequate health literacy who were English proficient (trials with errors per parent = 28.8 vs 12.9%; adjusted odds ratio = 2.2 [95% confidence interval 1.7-2.8]). Parents with limited health literacy who were English proficient were also more likely to make errors (trials with errors per parent = 18.8%; adjusted odds ratio = 1.4 [95% confidence interval 1.1-1.9]).Dosing errors are common among Hispanic parents; those with both LEP and limited health literacy are at particular risk. Further study is needed to examine how the redesign of medication labels and dosing tools could reduce literacy- and language-associated disparities in dosing errors.

    View details for Web of Science ID 000401298200010

    View details for PubMedID 28477800

  • Parent Preferences and Perceptions of mLs and Teaspoons: Role of Health Literacy and Experience. Academic pediatrics Torres, A., Parker, R. M., Sanders, L. M., Wolf, M. S., Bailey, S., Patel, D. A., Jimenez, J. J., Kim, K. A., Dreyer, B. P., Mendelsohn, A., Yin, H. S. 2017


    A recent American Academy of Pediatrics policy statement recommends milliliter-exclusive dosing for pediatric liquid medications. Little is known about parent preferences regarding units, perceptions about moving to milliliters only, and the role of health literacy and prior milliliter-dosing experience.Cross-sectional analysis of data collected as part of a randomized controlled study in 3 urban pediatric clinics (SAFE Rx for Kids study). English- and Spanish-speaking parents (n = 493) of children aged ≤8 years were randomized to 1 of 4 study arms and given labels and dosing tools which varied in label instruction format (text plus pictogram, text only) and units (milliliter only ["mL"], milliliter/teaspoon ["mL"/"tsp"]). Outcomes included teaspoon preference in dosing instructions and perceived difficulty with milliliter-only dosing. The predictor variable was health literacy (Newest Vital Sign; low [0-1], marginal [2-3], adequate [4-6]). The mediating variable was prior milliliter-dosing experience.Over two-thirds of parents had low or marginal health literacy. The majority (>70%) preferred to use milliliters, perceived milliliter-only dosing to be easy, and had prior milliliter-dosing experience; 11.5% had a teaspoon preference, 18.1% perceived milliliter-only dosing will be difficult, and 17.7% had no prior milliliter-dosing experience. Parents with lower health literacy had a higher odds of having a teaspoon preference (low vs adequate: adjusted odds ratio [AOR] = 2.9 [95% confidence interval [CI] 1.3-6.2]), and greater odds of perceiving difficulty with milliliter-only dosing (low vs adequate: AOR = 13.9 [95% CI 4.8-40.6], marginal vs adequate: AOR = 7.1 [95% CI 2.5-20.4]). Lack of experience with milliliter dosing partially mediated the impact of health literacy.Most parents were comfortable with milliliter-only dosing. Parents with low health literacy were more likely to perceive milliliter-only dosing to be difficult; educational efforts will need to target this group to ensure safe medication use.

    View details for DOI 10.1016/j.acap.2017.04.001

    View details for PubMedID 28400304

  • Adolescent and young adult oncology patients: Disparities in access to specialized cancer centers. Cancer Alvarez, E., Keegan, T., Johnston, E. E., Haile, R., Sanders, L., Saynina, O., Chamberlain, L. J. 2017


    Adolescents and young adults (AYAs) ages 15 to 39 years with cancer continue to experience disparate survival outcomes compared with their younger and older counterparts. This may be caused in part by differential access to specialized cancer centers (SCCs), because treatment at SCCs has been associated with improved overall survival. The authors examined social and clinical factors associated with AYA use of SCCs (defined as Children's Oncology Group-designated or National Cancer Institute-designated centers).A retrospective, population-based analysis was performed on all hospital admissions of AYA oncology patients in California during 1991 through 2014 (n = 127,250) using the Office of Statewide Health Planning and Development database. Multivariable logistic regression analyses examined the contribution of social and clinical factors on always receiving care from an SCC (vs sometimes or never). Results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs).Over the past 20 years, the percentage of patients always receiving inpatient care at an SCC increased over time (from 27% in 1991 to 43% in 2014). In multivariable regression analyses, AYA patients were less likely to always receive care from an SCC if they had public insurance (OR, 0.64; 95% CI, 0.62-0.66), were uninsured (OR, 0.51; 95% CI, 0.46-0.56), were Hispanic (OR, 0.88; 95% CI, 0.85-0.91), lived > 5 miles from an SCC, or had a diagnosis other than leukemia and central nervous system tumors.Receiving care at an SCC was influenced by insurance, race/ethnicity, geography, and tumor type. Identifying the barriers associated with decreased SCC use is an important first step toward improving outcomes in AYA oncology patients. Cancer 2017. © 2017 American Cancer Society.

    View details for DOI 10.1002/cncr.30562

    View details for PubMedID 28241089

  • Satisfaction With Communication In Primary Care For Spanish-Speaking And English-Speaking Parents. Academic pediatrics Flower, K. B., Skinner, A. C., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A., Perrin, E. M. 2017


    Effective communication with primary care physicians is important yet incompletely understood for Spanish-speaking parents. We predicted lower satisfaction among Spanish-speaking compared to English-speaking Latino and non-Latino parents.Cross-sectional analysis at 2-month well visits within the Greenlight study at 4 pediatric resident clinics. Parents reported satisfaction with 14 physician communication items using the validated Communication Assessment Tool (CAT). High satisfaction was defined as "excellent" on each CAT item. Mean estimations compared satisfaction for communication items among Spanish- and English-speaking Latinos and non-Latinos. We used generalized linear regression modeling, adjusted for parent age, education, income, and clinic site. Among Spanish-speaking parents, we compared visits conducted in Spanish with and without an interpreter, and in English.Compared to English-speaking Latino (n = 127) and non-Latino parents (n = 432), fewer Spanish-speaking parents (n = 303) reported satisfaction with 14 communication items. No significant differences were found between English-speaking Latinos and non-Latinos. Greatest differences were found in the use of a greeting that made the parent comfortable (59.4% of Spanish-speaking Latinos endorsing "excellent" vs 77.5% English-speaking Latinos, P < .01) and discussing follow-up (62.5% of Spanish-speaking Latinos vs 79.8% English-speaking Latinos, P < .01). After adjusting for parent age, education, income, and study site, Spanish-speaking Latinos were still less likely to report high satisfaction with these communication items. Satisfaction was not different among Spanish-speaking parents when the physician spoke Spanish versus used an interpreter.Satisfaction with physician communication was associated with language but not ethnicity. Spanish-speaking parents less frequently report satisfaction with communication, and innovative solutions to enhance communication quality are needed.

    View details for DOI 10.1016/j.acap.2017.01.005

    View details for PubMedID 28104488

  • Effect of Medication Label Units of Measure on Parent Choice of Dosing Tool: A Randomized Experiment. Academic pediatrics Yin, H. S., Parker, R. M., Sanders, L. M., Dreyer, B. P., Mendelsohn, A., Bailey, S., Patel, D. A., Jimenez, J. J., Kim, K. A., Jacobson, K., Hedlund, L., Landa, R., Maness, L., Tailor Raythatha, P., McFadden, T., Wolf, M. S. 2016; 16 (8): 734-741


    Some experts recommend eliminating "teaspoon" and "tablespoon" terms from pediatric medication dosing instructions, because these terms could inadvertently encourage use of nonstandard tools (ie, kitchen spoons), which are associated with dosing errors. We examined whether use of "teaspoon" or "tsp" on prescription labels affects parents' choice of dosing tools, and the role of health literacy and language.Analysis of data collected as part of a controlled experiment (SAFE Rx for Kids [Safe Administration For Every Prescription for Kids] study), which randomized English- and Spanish-speaking parents (n = 2110) of children 8 years of age and younger to 1 of 5 groups, which varied in unit of measurement pairings on medication labels and dosing tools. Outcome assessed was parent self-reported choice of dosing tool. Parent health literacy was measured using the Newest Vital Sign.Seventy-seven percent had limited health literacy (36.0% low, 41.0% marginal); 35.0% completed assessments in Spanish. Overall, 27.7% who viewed labels containing either "tsp" or "teaspoon" units (alone or with "mL") chose nonstandard dosing tools (ie, kitchen teaspoon, kitchen tablespoon), compared with 8.3% who viewed "mL"-only labels (adjusted odds ratio [AOR] = 4.4 [95% confidence interval (CI), 3.3-5.8]). Odds varied based on whether "teaspoon" was spelled out or abbreviated ("teaspoon"-alone: AOR = 5.3 [95% CI, 3.8-7.3]); "teaspoon" with mL: AOR = 4.7 [95% CI, 3.3-6.5]; "tsp" with mL: AOR = 3.3 [95% CI, 2.4-4.7]; P < .001). Similar findings were noted across health literacy and language groups.Use of teaspoon units ("teaspoon" or "tsp") on prescription labels is associated with increased likelihood of parent choice of nonstandard dosing tools. Future studies might be helpful to examine the real-world effect of eliminating teaspoon units from medication labels, and identify additional strategies to promote the safe use of pediatric liquid medications.

    View details for DOI 10.1016/j.acap.2016.04.012

    View details for PubMedID 27155289

    View details for PubMedCentralID PMC5077678

  • Health care for children with diabetes mellitus from low-income families in Ontario and California: a population-based cohort study. CMAJ open Kaiser, S. V., Sundaram, V., Cohen, E., Shulman, R., Guan, J., Sanders, L., Guttmann, A. 2016; 4 (4): E729-E736


    Children with diabetes mellitus in low-income families have poor outcomes, but little is known as to how this relates to healthcare system structure. Our objective was to gain insight into how best to structure health systems to serve these children by describing their health care use in 2 health system models: a Canadian model, with an organized diabetes care network that includes generalists, and an American model, with targeted support services for children from low-income families.We performed a population-based retrospective cohort study involving children aged 1-17 years with type 1 diabetes mellitus. We used administrative data from between 2009 and 2012 from the California Children's Services program and Ontario. We used Ontario Drug Benefit Program enrolment to identify children from low-income families. Proportions of children receiving 2 or more routine diabetes visits per year were compared using χ2 tests, and diabetes-complication hospital admission rates were compared using direct standardization.More California children from low-income families (n = 4922) received routine care for diabetes from pediatric endocrinologists (63.9% v. 26.9%, p < 0.001) and used insulin pumps (22.8% v. 16.4%, p < 0.001) than Ontario children (n = 2050).California children from low-income families were less likely than Ontario children to receive 2 visits for routine diabetes care per year (64.7% v. 75.7%, p < 0.001), and had slightly higher per-patient year hospital admission rates for diabetes complications (absolute differences 0.02, 95% confidence interval [CI] 0.02-0.02, for boys; 0.03, 95% CI 0.03-0.03, for girls).Ontario children from low-income families received more routine diabetes care than did California children from low-income families. Both groups of children had clinically comparable rates of hospital admission for diabetes complications. Diabetes care networks that integrate generalists may play a role in improving access and outcomes for the growing population of children with diabetes.

    View details for DOI 10.9778/cmajo.20160075

    View details for PubMedID 28018888

    View details for PubMedCentralID PMC5173459

  • Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment PEDIATRICS Yin, H. S., Parker, R. M., Sanders, L. M., Dreyer, B. P., Mendelsohn, A. L., Bailey, S., Patel, D. A., Jimenez, J. J., Kim, K. A., Jacobson, K., Hedlund, L., Smith, M. C., Harris, L. M., McFadden, T., Wolf, M. S. 2016; 138 (4)
  • Racial and Ethnic Differences in Injury Prevention Behaviors Among Caregivers of Infants. American journal of preventive medicine Heerman, W. J., Perrin, E. M., Sanders, L. M., Yin, H. S., Coyne-Beasley, T., Bronaugh, A. B., Barkin, S. L., Rothman, R. L. 2016; 51 (4): 411-418


    African American and Latino children experience higher rates of traumatic injury and mortality, but the extent to which parents of different races and ethnicities disparately enact injury prevention behaviors has not been fully characterized. The objective of this study is to evaluate the association between caregiver race/ethnicity and adherence to injury prevention recommendations.This was a cross-sectional analysis of caregiver-reported baseline data from the Greenlight study, a cluster-randomized pediatric obesity prevention trial. Data were collected between 2010 and 2012 in four academic pediatric practices and analyzed in 2015. Non-adherence to injury prevention recommendations was based on five domains: car seat safety, sleeping safety, fire safety, hot water safety, and fall prevention.Among 864 caregiver-infant pairs (17.7% white, non-Hispanic; 49.9% Hispanic; 27.7% black, non-Hispanic; 4.7 % other, non-Hispanic), mean number of non-adherent injury prevention behaviors was 1.8 (SD=0.9). In adjusted regression, Hispanic caregivers had higher odds of non-adherence to car seat safety (AOR=2.1, 95% CI=1.2, 3.8), and lower odds of non-adherence with fall prevention (AOR=0.4, 95% CI=0.3, 0.7) compared with whites. Black, non-Hispanic caregivers had higher odds of non-adherence to car seat safety (AOR=2.4, 95% CI=1.3, 4.4) and sleeping safety (AOR=2.1, 95% CI=1.3, 3.2), but lower odds of fall prevention non-adherence (AOR=0.5, 95% CI=0.3, 0.8) compared with whites.A high prevalence of non-adherence to recommended injury prevention behaviors is common across racial/ethnic categories for caregivers of infants among a diverse sample of families from low-SES backgrounds.

    View details for DOI 10.1016/j.amepre.2016.04.020

    View details for PubMedID 27291075

  • Parent Language: A Predictor for Neurodevelopmental Follow-up Care Among Infants With Very Low Birth Weight. Academic pediatrics Eneriz-Wiemer, M., Saynina, O., Sundaram, V., Lee, H. C., Bhattacharya, J., Sanders, L. M. 2016; 16 (7): 645-652


    Preterm/very low birth weight infants may suffer neurodevelopmental delays. Pediatricians should monitor neurodevelopment and pursue timely referrals. Yet parents who speak non-English primary languages (NEPL) report worse health care communication and fewer appropriate specialty referrals for their children. We sought to determine whether infants of NEPL parents receive recommended outpatient follow-up care for neurodevelopment. We hypothesized that these infants received less care than infants of English speakers.We linked paid claims from California Children's Services to clinical data from California Perinatal Quality Care Collaborative (58% linkage rate, 1541 subjects) for publicly insured infants with birth weight <1500 g or gestational age ≤32 weeks. Our primary outcomes were completion of 1) preventive visits and 2) ophthalmology visits; and receipt of 3) influenza vaccination and 4) palivizumab. To compare group differences, we also assessed 5) hospital length of stay and 6) readmissions. Analyses were adjusted for medical severity and sociodemographic characteristics.A total of 433 infants (28%) had NEPL parents. Infants of NEPL parents had 38% higher odds of receiving influenza vaccination (95% confidence interval 9-75, P = .008) and completed 8% more preventive visits (95% confidence interval 1-64, P = .019) than infants of English speakers. Infants of NEPL parents did not have longer lengths of stay or more readmissions.Infants of NEPL parents were more likely than infants of English speakers to receive some aspects of recommended outpatient follow-up care. Regardless of language, all infants received far lower rates of follow-up care than recommended by national guidelines. Future study should address the causes of these gaps.

    View details for DOI 10.1016/j.acap.2016.04.004

    View details for PubMedID 27130810

  • Small-for-Gestational-Age Births are Associated with Maternal Relationship Status: A Population-Wide Analysis MATERNAL AND CHILD HEALTH JOURNAL Steinberg, J. R., Sanders, L., Cousens, S. 2016; 20 (8): 1651-1661


    Objectives To examine the association between maternal relationship status during pregnancy and infant birth outcomes. Methods Observational study of the National Longitudinal Survey of Youth 1979, a nationally representative sample of 12,686 men and women between the ages of 14 and 21. We used data from surveys of women reporting childbirth between 1979 and 2004. Relationship status was defined as relationship with an opposite-sex partner in the child's birth year. Relationship stability was defined as the consistency in relationship status in the 1 year before, of, and after the child's birth. Childbirth outcome included small-for-gestational age (SGA) infant. We applied random effects logistic regression models to assess the association between relationship status and stability and childbirth outcome-adjusting for maternal race, infant sex, history of miscarriage, employment, maternal age, multiparity, cohort-entry year, household poverty status, and tobacco use. Results The study included 4439 women with 8348 live births. In fully adjusted models, term SGA infants were more commonly born to partnered women (AOR 1.81; 95 % CI 1.20-2.73) and unmarried women (AOR 1.82; CI 1.34-2.47; LRT p value 0.0001), compared to married women. SGA infants were also more commonly born in unstable relationships (AOR 1.72; 95 % CI 1.14-2.63; LRT p value 0.01) compared to stable relationships. Conclusions for Practice Maternal relationship status and stability during pregnancy is independently associated with risk of SGA infant birth.

    View details for DOI 10.1007/s10995-016-1964-6

    View details for Web of Science ID 000379347900009

    View details for PubMedID 27007984

  • Infant Sleep and Parent Health Literacy ACADEMIC PEDIATRICS Bathory, E., Tomopoulos, S., Rothman, R., Sanders, L., Perrin, E. M., Mendelsohn, A., Dreyer, B., Cerra, M., Yin, H. S. 2016; 16 (6): 550-557


    Child sleep problems are prevalent and have been linked to poor behavior, worse school performance, and obesity. Low health literacy (HL) is associated with suboptimal parenting practices and worse health outcomes, but the relationship between parent HL and child sleep-related issues is not known. We examined the association between parent HL and child sleep-related issues.This was a cross-sectional analysis of data from caregivers enrolled in a cluster randomized trial of a primary care-based child obesity prevention program in 4 pediatric clinics. Parent HL was assessed using the Short Test of Functional Health Literacy in Adults. At the 9-month well-child visit, sleep-related factors were assessed: presence of TV in room where child sleeps, regular naptimes and bedtimes (≥5 days/wk), low daytime and nighttime sleep duration (>1 SD below mean on the basis of national data). Multiple logistic regression analyses were performed.We enrolled 557 caregivers of 9-month-old children (49.7% Hispanic, 26.9% black, 56.2% <$20,000 annual income); 49.6% reported having a TV in the room where their child sleeps; 26.6% did not have regular naptimes norbedtimes. Median sleep duration was 2.3 (interquartile range, 1.5-3.0) hours (daytime), and 9.0 (interquartile range, 8.0-10.0) hours (night) (30.2% low daytime; 20.3% low nighttime sleep duration). Children of parents with low HL were more likely to have a bedroom TV (66.7% vs 47.7%, P = .01; adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.3) and low night-time sleep (37.0% vs 18.5%; P = .002; adjusted odds ratio, 2.4; 95% confidence interval, 1.2-4.8).Low parent HL is associated with TV in the bedroom and low night sleep duration. Additional study is needed to further explore these associations and intervention strategies to address child sleep problems.

    View details for Web of Science ID 000381063900009

    View details for PubMedID 26979779

    View details for PubMedCentralID PMC4975997

  • Parental Perceptions of Weight During the First Year of Life. Academic pediatrics Brown, C. L., Skinner, A. C., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A. M., Ravanbakht, S. N., Perrin, E. M. 2016; 16 (6): 558-564


    More than half of parents underestimate their overweight child's weight; however, previous research focuses on children older than 2 years of age. The objective of this study was to assess whether parents of 2- to 12-month-old infants are able to accurately perceive their children's weight status.We performed a cross-sectional analysis of data collected from the Greenlight study, a cluster randomized obesity prevention trial, at 4 pediatric clinics serving diverse and low-income populations. Infants' length and weight were measured at well-child checks, and parents completed questionnaires including demographic characteristics and perception of their children's weight. Weight-for-length (WFL) percentile at the fifth to ≤95 was considered healthy weight and WFL percentile >95th was considered overweight. We used chi-squared tests to compare accuracy according to weight category and performed logistic regression analysis to assess accuracy at each time point.Approximately 85% to 90% of infants (n = 853 at 2 months, n = 563 at 12 months) were at a healthy WFL at all measurement times, and parents of these infants were more likely to have an accurate perception of their child's weight (accuracy 89%-95%) than overweight children (accuracy 7%-26%; P < .001 across time points). Approximately 10% of healthy weight infants were perceived as underweight by their parents at all time points. At 12 months, mothers who were overweight were significantly more likely to underestimate their child's weight status (P = .008).In our diverse and low-income sample, parents of overweight infants infrequently know that their infants are overweight. Future studies should examine how perception is related to feeding habits and weight status over time.

    View details for DOI 10.1016/j.acap.2016.03.005

    View details for PubMedID 27002214

  • Bottle Size and Weight Gain in Formula-Fed Infants PEDIATRICS Wood, C. T., Skinner, A. C., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A. M., Perrin, E. M. 2016; 138 (1)


    Formula-fed infants may be at greater risk for overfeeding and rapid weight gain. Different size bottles are used for feeding infants, although little is known about whether bottle size is related to weight gain in bottle-fed infants.Data from the Greenlight Intervention Study, a cluster randomized trial to prevent childhood obesity at 4 pediatric resident clinics, were used to analyze the exposure to regular (<6 oz) or large (≥6 oz) bottle size at the 2-month visit on changes in weight, weight-for-age z score (WAZ), and weight-for-length z score (WLZ) at the 6-month visit. Using multivariable regression, we adjusted for potential confounders (birth weight, gender, age, weight measures at 2 months, parent race/ethnicity, education, household income and size, time between 2- and 6-month visits, and first child status).Forty-five percent (n = 386; 41% black, 35% Hispanic, 23% white, 2% other) of infants at the 2-month visit were exclusively formula-fed, and 44% used large (≥6 oz) bottles. Infants whose parents fed with large bottles had 0.21 kg (95% confidence interval [CI]: 0.05 to 0.37) more weight change, 0.24 U (95% CI: 0.07 to 0.41) more change in WAZ, and 0.31 U (95% CI: 0.08 to 0.54) more change in WLZ during this period than infants fed with regular bottles.Using a large bottle in early infancy independently contributed to greater weight gain and change in WLZ at the 6-month visit. Although growth in infancy is complex, bottle size may be a modifiable risk factor for rapid infant weight gain and later obesity among exclusively formula-fed infants.

    View details for DOI 10.1542/peds.2015-4538

    View details for Web of Science ID 000378853100026

    View details for PubMedID 27273748

  • Outpatient Care Preceding Hospitalization for Diabetic Ketoacidosis PEDIATRICS Crossen, S. S., Wilson, D. M., Saynina, O., Sanders, L. M. 2016; 137 (6)


    To identify patterns of outpatient care associated with diabetic ketoacidosis (DKA) among pediatric patients with type 1 diabetes (T1D).Retrospective cohort study using Medicaid claims data from 2009 to 2012 for children with T1D enrolled ≥365 consecutive days in California Children's Services, a Title V program for low-income children with chronic disease. Outcome was DKA hospitalization >30 days after enrollment. Outpatient visits to primary care, endocrinology, pharmacies, and emergency departments (EDs) were assessed during the 6 months before an index date: either date of first DKA hospitalization or end of enrollment for those without DKA. Univariate and multivariate analysis was used to evaluate independent associations between DKA and outpatient care at clinically meaningful intervals preceding the index date.Among 5263 children with T1D, 16.7% experienced DKA during the study period. Patients with DKA were more likely to have had an ED visit (adjusted odds ratio [aOR] 3.99, 95% confidence interval [CI]: 2.60-6.13) or a nonpreventive primary care visit (aOR 1.35, 95% CI: 1.01-1.79) within 14 days before the index date, and less likely to have visited an endocrinologist (aOR 0.76, 95% CI: 0.65-0.89) within the preceding 120 days. Preventive visits and pharmacy claims were not associated with DKA.For children with T1D, recent ED visits and long intervals without subspecialty care are important signals of impending DKA. Combined with other known risk factors, these health-use indicators could be used to inform clinical and case management interventions that aim to prevent DKA hospitalizations.

    View details for DOI 10.1542/peds.2015-3497

    View details for Web of Science ID 000378520100021

    View details for PubMedID 27207491

  • Confirmatory factor analysis of the Infant Feeding Styles Questionnaire in Latino families. Appetite Wood, C. T., Perreira, K. M., Perrin, E. M., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A. M., Bentley, M. E., Bronaugh, A. B., Thompson, A. L. 2016; 100: 118-125


    Parent feeding practices affect risk of obesity in children. Latino children are at higher risk of obesity than the general population, yet valid measure of feeding practices, one of which is the Infant Feeding Styles Questionnaire (IFSQ), have not been formally validated in Spanish.To validate the IFSQ among Latino families, we conducted confirmatory factor analysis of pressuring, restrictive, and responsive feeding constructs from the IFSQ.The IFSQ was administered at the 12-month visit in the Greenlight study, a multi-center cluster randomized trial to prevent obesity. Parents were included if they were of Latino origin (n = 303) and completed an English or Spanish language modified IFSQ (without the indulgence construct). Scores from nine sub-constructs of the IFSQ were compared between English and Spanish language versions. We tested reliability with Cronbach's alpha coefficients and performed confirmatory factor analysis to examine factor loadings and goodness of fit characteristics, modifying constructs to achieve best fit.Of 303 parents completing the IFSQ, 84% were born outside the US, and 74% completed the IFSQ in Spanish. Reliability coefficients ranged from 0.28 to 0.61 for the laissez-faire sub-constructs and from 0.58 to 0.83 for the pressuring, restrictive, and responsive sub-constructs. Results for all coefficients were similar between participants responding to an English and Spanish version of the IFSQ. Goodness of fit indices ranged from CFI 0.82-1 and RMSEA 0.00-0.31, and the model performed best in pressuring-soothing (CFI 1.0, RMSEA 0.00) and restrictive-amount (CFI 0.98, RMSEA 0.1) sub-constructs.In a sample of Latino families, pressuring, restrictive, and responsive constructs performed well. The modified IFSQ in both English and Spanish-speaking Latino families may be used to assess parenting behaviors related to early obesity risk in this at-risk population.

    View details for DOI 10.1016/j.appet.2016.02.018

    View details for PubMedID 26876910

  • Association Between Bottle Size and Formula Intake in 2-Month-Old Infants ACADEMIC PEDIATRICS Wood, C. T., Skinner, A. C., Yin, H. S., Rothman, R. L., Sanders, L. M., Delamater, A., Ravanbakht, S. N., Perrin, E. M. 2016; 16 (3): 254-259


    To determine range of bottle sizes used and examine the relationship between bottle size and total daily consumption of infant formula.Cross-sectional analysis of baseline data collected as part of Greenlight, a cluster randomized trial to prevent childhood obesity at 4 pediatric resident clinics. The Greenlight study included healthy, term infants. For our analysis, parents of exclusively formula-fed infants reported volume per feed, number of feeds per day, and bottle size, which was dichotomized into small (<6 oz) or large (≥6 oz). We identified determinants of bottle size, and then examined relationships between bottle size and volume fed with log-transformed ordinary least squares regression, adjusting for infant age, sex, birth weight, current weight, race/ethnicity, and enrollment in Special Supplemental Nutrition Program for Women, Infants, and Children.Of 865 participants in the Greenlight study, 44% (n = 378; 21.8% white, 40.6% black, 35.3% Hispanic, 2.4% other) of infants were exclusively formula fed at 2 months. Median volume per day was 30 oz (interquartile range 12), and 46.0% of infants were fed with large bottles. Adjusted for covariates, parents using larger bottles reported feeding 4 oz more formula per day (34.2 oz, 95% confidence interval 33.5-34.9 vs 29.7 oz, 95% confidence interval 29.2-30.3, P = .03).Among exclusively formula-fed infants, use of a larger bottle is associated with parental report of more formula intake compared to infants fed with smaller bottles. If infants fed with larger bottles receive more formula, these infants may be overfed and consequently at risk for obesity.

    View details for Web of Science ID 000373417500007

    View details for PubMedID 26525989

  • Assessing Differences in Mortality Rates and Risk Factors Between Hispanic and Non-Hispanic Patients With Cystic Fibrosis in California CHEST Buu, M. C., Sanders, L. M., Mayo, J. A., Milla, C. E., Wise, P. H. 2016; 149 (2): 380-389
  • Psychosocial Health, e-Health Literacy, and Perceptions of e-Health as Predictors and Moderators of e-Health Use Among Caregivers of Children with Special Healthcare Needs TELEMEDICINE AND E-HEALTH Sarkar, M., Sanders, L. M., Kelleher, K. J., Chisolm, D. J. 2016; 22 (2): 123-131
  • Training Health Care Professionals for 21st-Century Practice: A Systematic Review of Educational Interventions on Chronic Care ACADEMIC MEDICINE Bogetz, J. F., Rassbach, C. E., Bereknyei, S., Mendoza, F. S., Sanders, L. M., Braddock, C. H. 2015; 90 (11): 1561-1572


    To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care.A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention.A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives.The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.

    View details for DOI 10.1097/ACM.0000000000000773

    View details for Web of Science ID 000363973300032

    View details for PubMedID 26039140

  • Predictors of Health Literacy and Numeracy Concordance Among Adolescents With Special Health Care Needs and Their Parents JOURNAL OF HEALTH COMMUNICATION Chisolm, D. J., Sarkar, M., Kelleher, K. J., Sanders, L. M. 2015; 20: 43-49
  • Patient-centered medical home for patients with complex congenital heart disease. Current opinion in pediatrics Fernandes, S. M., Sanders, L. M. 2015; 27 (5): 581-586


    Originally conceived by pediatricians as a model for the care of children with special healthcare needs, the 'patient-centered medical home' (PCMH) has been identified by the Affordable Care Act as a model for all future outpatient care delivery. Although few studies have demonstrated its efficacy in improving care for children with congenital heart disease (CHD), access to a PCMH is likely to improve CHD-patient outcomes, including global function and quality of life, while reducing healthcare costs.To date, most patients with complex CHD have their care anchored in cardiology subspecialty-care clinics, which lack many of the attributes of a PCMH. Given that many of these patients have noncardiac morbidities, including neurocognitive impairment and multiorgan dysfunction, we believe such patients will benefit from a PCMH model of care based on primary care.The PCMH based on primary care for patients with complex CHD could result in improved clinical outcomes, improved patient satisfaction and quality of life as well as decreased healthcare costs. Policy and practice reform are required to increase CHD-patient access to a PCMH, based on primary-care settings.

    View details for DOI 10.1097/MOP.0000000000000258

    View details for PubMedID 26348668

  • Early Literacy Promotion in the Digital Age. Pediatric clinics of North America Navsaria, D., Sanders, L. M. 2015; 62 (5): 1273-1295


    School readiness and educational success is strongly mediated by early literacy skills. In both exam-room and community-based settings, child-health providers can affect the trajectory of early literacy by implementing evidence-based, culturally appropriate interventions that support child development, parenting skills, and child-caregiver interaction. Despite limited research on the subject, these interventions should also attend to the evolving role of digital-media exposure (both positive and negative) on the developmental health of children.

    View details for DOI 10.1016/j.pcl.2015.06.002

    View details for PubMedID 26318952

  • Psychosocial Health, e-Health Literacy, and Perceptions of e-Health as Predictors and Moderators of e-Health Use Among Caregivers of Children with Special Healthcare Needs. Telemedicine journal and e-health : the official journal of the American Telemedicine Association Sarkar, M., Sanders, L. M., Kelleher, K. J., Chisolm, D. J. 2015: -?


    In this study, we explored the relationships between the psychosocial health of caregivers of children with special healthcare needs and their e-health use. Additionally, the analysis examined moderating effects of a caregiver's perceptions of e-health and his or her e-health literacy on the associations among four domains of psychosocial health and e-health use.To date, 313 caregivers of children, 12-18 years of age, with special healthcare needs have been recruited. Covariate-adjusted multivariable regressions determined associations between psychosocial health domains of caregivers and e-health use. E-health literacy and perceptions of e-health were further tested as moderators of the relationship between psychosocial health and e-health use.Among the caregiver population, 31% had problems with social functioning, 36.1% with communication, 43.3% with family relationships, and 46.3% with worrying for their child. After adjusting for demographic variables, e-health use was associated with poorer levels of social functioning, communication, worry, and family relationship. E-health use was also associated with e-health literacy. Perceptions of e-health significantly moderated the relationships among social functioning, communication, and e-health, with the relationship being significantly stronger in caregivers with more positive perceptions of e-health.Caregivers of children with special healthcare needs have notable levels of psychosocial challenges and those challenges are associated with their e-health resource seeking. Although e-health interventions, including ones that focus on child health education and caregiver support, may be the future of healthcare, a concerted effort is needed to educate caregivers about the benefits of e-health.

    View details for PubMedID 26295487

  • Health Care Utilization and Costs of Publicly-Insured Children with Diabetes in California. journal of pediatrics Lee, J. M., Sundaram, V., Sanders, L., Chamberlain, L., Wise, P. 2015; 167 (2): 449-54 e6


    To examine diabetes-related health care utilization and costs for a population-based sample of children with presumed type 1 diabetes (T1D) enrolled in the California Children's Services program.Our data source was the California Children's Services claims data for the period July 1, 2009, to June 30, 2012. We studied a sample of 652 children aged 0-21 years who were continuously enrolled for at least 365 days, had an outpatient visit for T1D, and were taking insulin.Compared with the younger age groups, individuals in the 19-21 year age group had the highest rates of hospitalization, T1D-specific bed-days, and emergency department visits. The overall median cost for this population was $7654. The overall median costs per year (and proportion of total costs) were $5603 (59%) for hospitalizations, $58 (0.4%) for emergency department visits, $144 (1.3%) for outpatient utilization, $2930 (23%) for insulin, and $1579 (13%) for blood glucose monitoring supplies. For those who used them, the median cost of pumps was an additional $2162.Further studies are needed to provide more insight into patterns of care and adverse health outcomes for children with T1D as they transition into young adulthood. The costs of insulin, glucose monitoring supplies, and pump therapy for children with T1D is substantial and may factor into future policy considerations regarding coverage and cost-sharing with families.

    View details for DOI 10.1016/j.jpeds.2015.04.067

    View details for PubMedID 26028286

  • Health Care Utilization and Costs of Publicly-Insured Children with Diabetes in California. journal of pediatrics Lee, J. M., Sundaram, V., Sanders, L., Chamberlain, L., Wise, P. 2015; 167 (2): 449-454 e6

    View details for DOI 10.1016/j.jpeds.2015.04.067

    View details for PubMedID 26028286

  • Outpatient Pharmacy Expenditures for Children With Serious Chronic Illness in California, 2010-2012. JAMA Swenson, S. M., Chamberlain, L. J., Sanders, L. M., Sundaram, V., Wise, P. H. 2015; 314 (4): 405-407

    View details for DOI 10.1001/jama.2015.7169

    View details for PubMedID 26219060

  • Variation in Use of Pediatric Cardiology Subspecialty Care A Total Population Study in California, 1983 to 2011 JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Chamberlain, L. J., Fernandes, S. M., Saynina, O., Grady, S., Sanders, L., Staves, K., Wise, P. H. 2015; 66 (1): 37-44


    American Academy of Pediatrics guidelines emphasize regionalized systems of care for pediatric chronic illness. There remains a paucity of information on the status of regionalized systems of care for pediatric congenital heart disease (CHD).This study evaluated variations in use of pediatric cardiology specialty care centers (PCSCC) for pediatric patients with CHD in California between 1983 and 2011.We performed a retrospective, total population analysis of pediatric CHD patients using the California Office of Statewide Health Planning and Development unmasked database. PCSCCs were identified by California's Title V program.There were 164,310 discharges meeting inclusion criterion. Discharges from PCSCCs grew from 58% to 88% between 1983 and 2011. Regionalized care was highest for surgical (96%) versus nonsurgical (71%) admissions. Admissions with a public payer increased from 42% (1983) to 61% (2011). Total bed days nearly doubled, and median length of stay increased from 2 to 3 days (nonspecialty care) and from 4 to 5 days (specialty care). There was a decrease in the pediatric CHD in-hospital death rate from 5.1 to 2.3 per 100,000 between 1983 and 2011, and a shift toward a larger percent of deaths occurring in the newborn period.California's inpatient regionalized specialty care of pediatric CHD has increased substantially since 1983, especially for surgical CHD discharges. The death rate has decreased, the number of bed days has increased, and a large proportion of these discharges now have public payers. Health care reform efforts must consider these shifts while protecting advances in regionalization of pediatric CHD care.

    View details for DOI 10.1016/j.jacc.2015.04.053

    View details for Web of Science ID 000357417900006

    View details for PubMedID 26139056

  • Outcomes of a Randomized Controlled Educational Intervention to Train Pediatric Residents on Caring for Children With Special Health Care Needs CLINICAL PEDIATRICS Bogetz, J. F., Gabhart, J. M., Rassbach, C. E., Sanders, L. M., Mendoza, F. S., Bergman, D. A., Blankenburg, R. L. 2015; 54 (7): 659-666


    Objective. To evaluate an innovative curriculum meeting new pediatric residency education guidelines, Special Care Optimization for Patients and Education (SCOPE). Methods. Residents were randomized to intervention (n = 23) or control (n = 25) groups. Intervention residents participated in SCOPE, pairing them with a child with special health care needs (CSHCN) and faculty mentor to make a home visit, complete care coordination toolkits, and participate in case discussions. The primary outcome was resident self-efficacy in nine skills in caring for CSHCN. Secondary outcomes included curriculum feasibility/acceptance, resident attitudes, and family satisfaction. Results. Response rates were ≥65%. Intervention residents improved in their self-efficacy for setting patient-centered goals compared with controls (mean change on 4-point Likert-type scale, 1.36 vs 0.56, P < .05). SCOPE was feasible/acceptable, residents had improved attitudes toward CSHCN, and families reported high satisfaction. Conclusion. SCOPE may serve as a model for efforts to increase residents' self-efficacy in their care of patients with chronic disease.

    View details for DOI 10.1177/0009922814564050

    View details for Web of Science ID 000354656600008

    View details for PubMedID 25561698

  • Trends in utilization of specialty care centers in california for adults with congenital heart disease. American journal of cardiology Fernandes, S. M., Chamberlain, L. J., Grady, S., Saynina, O., Opotowsky, A. R., Sanders, L., Wise, P. H. 2015; 115 (9): 1298-1304


    The American College of Cardiology and American Heart Association guidelines recommend that management of adult congenital heart disease (ACHD) be coordinated by specialty ACHD centers and that ACHD surgery for patients with moderate or complex congenital heart disease (CHD) be performed by surgeons with expertise and training in CHD. Given this, the aim of this study was to determine the proportion of ACHD surgery performed at specialty ACHD centers and to identify factors associated with ACHD surgery being performed outside of specialty centers. This retrospective population analysis used California's Office of Statewide Health Planning and Development's discharge database to analyze ACHD cardiac surgery (in patients 21 to 65 years of age) in California from 2000 to 2011. Designation as a "specialty ACHD center" was defined on the basis of a national ACHD directory. A total of 4,611 ACHD procedures were identified. The proportion of procedures in patients with moderate and complex CHD delivered at specialty centers increased from 46% to 71% from 2000 to 2011. In multivariate analysis among those discharges for ACHD surgery in patients with moderate or complex CHD, performance of surgery outside a specialty center was more likely to be associated with patients who were older, Hispanic, insured by health maintenance organizations, and living farther from a specialty center. In conclusion, although the proportion of ACHD surgery for moderate or complex CHD being performed at specialty ACHD centers has been increasing, 1 in 4 patients undergo surgery at nonspecialty centers. Increased awareness of ACHD care guidelines and of the patient characteristics associated with differential access to ACHD centers may help improve the delivery of appropriate care for all adults with CHD.

    View details for DOI 10.1016/j.amjcard.2015.02.013

    View details for PubMedID 25765587

  • The Relationship Between Acculturation and Infant Feeding Styles in a Latino Population OBESITY Dancel, L. D., Perrin, E., Yin, H. S., Sanders, L., Delamater, A., Perreira, K. M., Bronaugh, A. B., Eden, S., Shintani, A., Rothman, R. L. 2015; 23 (4): 840-846


    To assess the relationship between parental acculturation and infant feeding style in a sample of Latino parents.A post hoc analysis was performed using data from an ongoing four-site randomized controlled trial to promote early childhood obesity prevention. Cross-sectional data of parent-child dyads at the 12-month well-child visit who self-reported their Latino ethnicity were analyzed. The Short Acculturation Scale for Hispanics (SASH) and a subset of the Infant Feeding Style Questionnaire (IFSQ) that assessed four primary feeding styles were administered. SASH level (low vs. high) with each feeding style was compared by analyses.Complete SASH data were available for 398 of 431 Latino dyads. Median SASH score was 1.8 (IQR 1.4-2.7); 82% of participants had low acculturation (score < 3). Of the nine outcome variables, four were significantly associated with SASH: "Laissez-Faire/attention" (AOR: 2.3; 95% CI: 1.06-5.13; P = 0.004), "Laissez-Faire/diet quality" (AOR: 3.9; 95% CI: 1.7-8.75; P = 0.005), "Pressuring as soothing" (AOR: 3.6; 95% CI:1.63-8.05; P = 0.007), and "Restrictive/diet quality" (AOR: 0.4; 95% CI: 0.19-0.94; P = 0.031).Latino parents with lower acculturation were more likely than those with higher acculturation to endorse feeding styles that are associated with child obesity. Further research is needed to determine why acculturation and feeding style relate.

    View details for DOI 10.1002/oby.20986

    View details for Web of Science ID 000351832400019

    View details for PubMedID 25755135

  • Teaching Health Advocacy to Medical Students: A Comparison Study JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE Belkowitz, J., Sanders, L. M., Zhang, C., Agarwal, G., Lichtstein, D., Mechaber, A. J., Chung, E. K. 2014; 20 (6): E10-E19
  • Teaching health advocacy to medical students: a comparison study. Journal of public health management and practice Belkowitz, J., Sanders, L. M., Zhang, C., Agarwal, G., Lichtstein, D., Mechaber, A. J., Chung, E. K. 2014; 20 (6): E10-9


    Many encourage service learning and health advocacy training in medical student education, but related evaluation is limited.To assess (1) impact of a required community health advocacy training for medical students on student attitudes, knowledge, and skills; (2) student characteristics associated with higher advocacy knowledge and skills; and (3) perspectives of community-based organizations (CBOs).Cross-sectional surveys.University of Miami Miller School of Medicine (UMMSM) Regional Medical Campus and main campus.Medical students at both UMMSM campuses.Required community health advocacy training for first- and second-year students including classroom experiences and hands-on project in partnership with a CBO.Student characteristics, health advocacy-related attitudes, self-reported and objective knowledge, and skills. Scores were compared between campuses, with multivariable modeling adjusting for individual student characteristics. Community-based organization perspectives were assessed via separate surveys.Ninety-eight (77%) regional campus students (intervention group) and 139 (30%) main campus students (comparison group) completed surveys. Versus the comparison group, the intervention group reported greater: mean knowledge of community health needs: 34.6 versus 31.1 (range: 11-44, P < .01), knowledge about CBOs: 3.0 versus 2.7 (range 1-4, P < .01) and knowledge of community resources: 5.4 versus 2.3 (range, 0-11, P < .01), and mean skill scores: 12.7 versus 10.5 (score range: 4-16, P < .01), following the intervention. Using adjusted analysis across both groups, female gender was associated with higher attitudes score. High level of previous community involvement was associated with higher attitude and skill scores. Higher self-reported educational debt was associated with higher skill scores. Community-based organization perspectives included high satisfaction and a desire to influence the training of future physicians.Medical student advocacy training in partnership with community-based organizations could be beneficial in improving student advocacy knowledge and skills in addressing community health issues and in developing sustainable community partnerships.

    View details for DOI 10.1097/PHH.0000000000000031

    View details for PubMedID 24322841

  • Assessing Patient Experiences in the Pediatric Patient-Centered Medical Home: A Comparison of Two Instruments MATERNAL AND CHILD HEALTH JOURNAL Knapp, C., Chakravorty, S., Madden, V., Baron-Lee, J., Gubernick, R., Kairys, S., Pelaez-Velez, C., Sanders, L. M., Thompson, L. 2014; 18 (9): 2124-2133
  • Characteristics and Direct Costs of Academic Pediatric Subspecialty Outpatient No-Show Events JOURNAL FOR HEALTHCARE QUALITY Perez, F. D., Xie, J., Sin, A., Tsai, R., Sanders, L., Cox, K., Haberland, C. A., Park, K. T. 2014; 36 (4): 32-42


    BACKGROUND: Clinic no shows (NS) create a lost opportunity for provider-patient interaction and impose a financial burden to the healthcare system and on society. We aimed to: (1) to determine the clinical and demographic factors associated with increased NS rates at a children's hospital's subsubspecialty clinics and (2) to estimate the direct institutional financial costs associated with NS events. METHODS: A comprehensive database was generated from all clinic encounters for 15 subspecialty outpatient clinics (five surgical and 10 medical) between September 12, 2005 and December 30, 2010. Multivariate logistic regressions were performed to identify the variables associated with NS events. Direct costs of NS events were estimated using annual revenue for each clinic. RESULTS: A total of 284,275 encounters and 17,024 NS events were available for analysis. Public insurance coverage (Medicaid and Title V), compared to private insurance or self-pay status, was associated with an increased likelihood NS (OR 2.19, 95% CI 2.10-2.28, p < 0.0005 for Medicaid; OR 1.56, 95% CI 1.50-1.62, p < 0.0005 for Title V). Compared to patients 21-30 years of age, patients <12 years (OR 2.08, 95% CI 1.77-2.45, p < 0.0005) had increased likelihood of NS. Scheduled visits with medical subspecialists were more likely than surgical subspecialty visits to result in a NS (OR 1.69, 95% CI 1.63-1.75, p < 0.0005). The predicted annualized lost revenue associated with NS visits was estimated at $730,000 from the 15 clinics analyzed, approximately $210 per NS event. CONCLUSION: Pediatric subspecialty NS events are common, costly, and potentially preventable.

    View details for Web of Science ID 000348450800003

    View details for PubMedID 23551280

  • "Greenlight study": a controlled trial of low-literacy, early childhood obesity prevention. Pediatrics Sanders, L. M., Perrin, E. M., Yin, H. S., Bronaugh, A., Rothman, R. L. 2014; 133 (6): e1724-37


    Children who become overweight by age 2 years have significantly greater risks of long-term health problems, and children in low-income communities, where rates of low adult literacy are highest, are at increased risk of developing obesity. The objective of the Greenlight Intervention Study is to assess the effectiveness of a low-literacy, primary-care intervention on the reduction of early childhood obesity. At 4 primary-care pediatric residency training sites across the US, 865 infant-parent dyads were enrolled at the 2-month well-child checkup and are being followed through the 24-month well-child checkup. Two sites were randomly assigned to the intervention, and the other sites were assigned to an attention-control arm, implementing the American Academy of Pediatrics' The Injury Prevention Program. The intervention consists of an interactive educational toolkit, including low-literacy materials designed for use during well-child visits, and a clinician-centered curriculum for providing low-literacy guidance on obesity prevention. The study is powered to detect a 10% difference in the number of children overweight (BMI > 85%) at 24 months. Other outcome measures include observed physician-parent communication, as well as parent-reported information on child dietary intake, physical activity, and injury-prevention behaviors. The study is designed to inform evidence-based standards for early childhood obesity prevention, and more generally to inform optimal approaches for low-literacy messages and health literacy training in primary preventive care. This article describes the conceptual model, study design, intervention content, and baseline characteristics of the study population.

    View details for DOI 10.1542/peds.2013-3867

    View details for PubMedID 24819570

  • How do Breast Imaging Centers Communicate Results to Women with Limited English Proficiency and Other Barriers to Care? JOURNAL OF IMMIGRANT AND MINORITY HEALTH Marcus, E. N., Koru-Sengul, T., Miao, F., Yepes, M., Sanders, L. 2014; 16 (3): 401-408


    Research suggests that women with Limited English Proficiency (LEP) and ethnic minority women are at increased risk of being inadequately informed of their mammogram result. The purpose of this study is to explore breast imaging centers' communication practices and assess how these centers accommodate women with low literacy and LEP. A 35-question survey was distributed to a national association of more than 700 breast health centers. Descriptive analysis of the overall sample and Fisher's exact or Chi squared testing to distinguish differences between subgroups were performed. Respondents from 206 centers completed questionnaires. 29% of respondents stated that more than a quarter of their patients were black, 27% of respondents stated that more than a quarter of their patients were Hispanic/Latina, and 13% of respondents stated that more than a quarter of their patients had LEP. Overall, 18% of respondents reported they do not routinely telephone patients with results, 15% do not have multilingual staff or translators available to answer questions, and 69% send result letters in English only. Of note, 69% use patient navigators. Centers reported systemic strengths and barriers to clear communication of mammography results. Our findings are consistent with past investigations identifying a general need to improve the communication of breast imaging results and suggesting that result notification letters alone are inadequate in ensuring that every woman understands her personal results and follow-up plan.

    View details for DOI 10.1007/s10903-012-9771-7

    View details for Web of Science ID 000335771700010

    View details for PubMedID 23324987

  • Health Literacy and Injury Prevention Behaviors Among Caregivers of Infants AMERICAN JOURNAL OF PREVENTIVE MEDICINE Heerman, W. J., Perrin, E. M., Yin, H. S., Sanders, L. M., Eden, S. K., Shintani, A., Coyne-Beasley, T., Bronaugh, A. B., Barkin, S. L., Rothman, R. L. 2014; 46 (5): 449-456


    Unintentional injury is a leading cause of infant mortality.To examine the role of caregiver health literacy in infant injury prevention behaviors.A cross-sectional analysis of data collected in 2010-2012 from a randomized trial at four pediatric clinics was performed in 2012-2013. Caregiver health literacy was assessed with the Short Test of Functional Health Literacy in Adults. Caregiver-reported adherence to American Academy of Pediatrics-recommended injury prevention behaviors was assessed across seven domains: (1) car seat position; (2) car seat use; (3) sleeping safety; (4) fire safety; (5) hot water safety; (6) fall prevention; and (7) firearm safety.Data were analyzed from 844 English- and Spanish-speaking caregivers of 2-month-old children. Many caregivers were non-adherent with injury prevention guidelines, regardless of health literacy. Notably, 42.6% inappropriately placed their children in the prone position to sleep, and 88.6% did not have their hot water heater set <120°F. Eleven percent of caregivers were categorized as having low health literacy. Low caregiver health literacy, compared to adequate health literacy, was significantly associated with increased odds of caregiver non-adherence with recommended behaviors for car seat position (AOR=3.4, 95% CI=1.6, 7.1) and fire safety (AOR=2.0, 95% CI=1.02, 4.1) recommendations. Caregivers with low health literacy were less likely to be non-adherent to fall prevention recommendations (AOR=0.5, 95% CI=0.2, 0.9).Non-adherence to injury prevention guidelines was common. Low caregiver health literacy was significantly associated with some injury prevention behaviors. Future interventions should consider the role of health literacy in promoting injury prevention.

    View details for DOI 10.1016/j.amepre.2014.01.005

    View details for Web of Science ID 000334768400004

    View details for PubMedID 24745634

  • Measurement of Parental Self-Efficacy for Diabetes Management in Young Children CHILDRENS HEALTH CARE Marchante, A. N., Pulgaron, E. R., Daigre, A., Patino-Fernandez, A. M., Sanchez, J., Sanders, L. M., Delamater, A. M. 2014; 43 (2): 110-119
  • Racial and Ethnic Differences Associated With Feeding- and Activity- Related Behaviors in Infants PEDIATRICS Perrin, E. M., Rothman, R. L., Sanders, L. M., Skinner, A. C., Eden, S. K., Shintani, A., Throop, E. M., Yin, H. S. 2014; 133 (4): E857-E867


    To examine parental reports of feeding and activity behaviors in a cohort of parents of 2-month-olds and how they differ by race/ethnicity.Parents participating in Greenlight, a cluster, randomized trial of obesity prevention at 4 health centers, were queried at enrollment about feeding and activity behaviors thought to increase obesity risk. Unadjusted associations between race/ethnicity and the outcomes of interest were performed by using Pearson χ(2) and Kruskal-Wallis tests. Adjusted analyses were performed by using proportional odds logistic regressions.Eight hundred sixty-three parents (50% Hispanic, 27% black, 18% white; 86% Medicaid) were enrolled. Exclusive formula feeding was more than twice as common (45%) as exclusive breastfeeding (19%); 12% had already introduced solid food; 43% put infants to bed with bottles; 23% propped bottles; 20% always fed when the infant cried; 38% always tried to get children to finish milk; 90% were exposed to television (mean, 346 minutes/day); 50% reported active television watching (mean, 25 minutes/day); and 66% did not meet "tummy time" recommendations. Compared with white parents, black parents were more likely to put children to bed with a bottle (adjusted odds ratio [aOR] = 1.97, P < .004; bottle propping, aOR = 3.1, P < .001), and report more television watching (aOR = 1.6, P = .034). Hispanic parents were more likely than white parents to encourage children to finish feeding (aOR = 1.9, P = .007), bottle propping (aOR = 2.5, P = .009), and report less tummy time (aOR = 0.6, P = .037).Behaviors thought to relate to later obesity were highly prevalent in this large, diverse sample and varied by race/ethnicity, suggesting the importance of early and culturally-adapted interventions.

    View details for DOI 10.1542/peds.2013-1326

    View details for Web of Science ID 000335343500033

    View details for PubMedID 24639273

  • Parental limited English proficiency and health outcomes for children with special health care needs: a systematic review. Academic pediatrics Eneriz-Wiemer, M., Sanders, L. M., Barr, D. A., Mendoza, F. S. 2014; 14 (2): 128-136


    One in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.To conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.PubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.US studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.Three trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.From 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.Parental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.

    View details for DOI 10.1016/j.acap.2013.10.003

    View details for PubMedID 24602575

  • Parent health literacy and "obesogenic" feeding and physical activity-related infant care behaviors. journal of pediatrics Yin, H. S., Sanders, L. M., Rothman, R. L., Shustak, R., Eden, S. K., Shintani, A., Cerra, M. E., Cruzatte, E. F., Perrin, E. M. 2014; 164 (3): 577-583 e1


    To examine the relationship between parent health literacy and "obesogenic" infant care behaviors.Cross-sectional analysis of baseline data from a cluster randomized controlled trial of a primary care-based early childhood obesity prevention program (Greenlight). English- and Spanish-speaking parents of 2-month-old children were enrolled (n = 844). The primary predictor variable was parent health literacy (Short Test of Functional Health Literacy in Adults; adequate ≥23; low <23). Primary outcome variables involving self-reported obesogenic behaviors were: (1) feeding content (more formula than breast milk, sweet drinks, early solid food introduction), and feeding style-related behaviors (pressuring to finish, laissez-faire bottle propping/television [TV] watching while feeding, nonresponsiveness in letting child decide amount to eat); and (2) physical activity (tummy time, TV). Multivariate logistic regression analyses (binary, proportional odds models) performed adjusting for child sex, out-of-home care, Women, Infants, and Children program status, parent age, race/ethnicity, language, number of adults/children in home, income, and site.Eleven percent of parents were categorized as having low health literacy. Low health literacy significantly increased the odds of a parent reporting that they feed more formula than breast milk, (aOR = 2.0 [95% CI: 1.2-3.5]), immediately feed when their child cries (aOR = 1.8 [1.1-2.8]), bottle prop (aOR = 1.8 [1.002-3.1]), any infant TV watching (aOR = 1.8 [1.1-3.0]), and inadequate tummy time (<30 min/d), (aOR = 3.0 [1.5-5.8]).Low parent health literacy is associated with certain obesogenic infant care behaviors. These behaviors may be modifiable targets for low health literacy-focused interventions to help reduce childhood obesity.

    View details for DOI 10.1016/j.jpeds.2013.11.014

    View details for PubMedID 24370343

  • Parental Limited English Proficiency and Health Outcomes for Children With Special Health Care Needs: A Systematic Review ACADEMIC PEDIATRICS Eneriz-Wiemer, M., Sanders, L. M., Barr, D. A., Mendoza, F. S. 2014; 14 (2): 128-136


    One in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.To conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.PubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.US studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.Three trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.From 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.Parental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.

    View details for Web of Science ID 000333142500005

    View details for PubMedID 24602575

  • Glycemic control in young children with diabetes: The role of parental health literacy PATIENT EDUCATION AND COUNSELING Pulgaron, E. R., Sanders, L. M., Patino-Fernandez, A. M., Wile, D., Sanchez, J., Rothman, R. L., Delamater, A. M. 2014; 94 (1): 67-70


    This cross sectional study examined the relationship between parental health literacy (HL), diabetes related numeracy, and parental perceived diabetes self-efficacy on glycemic control in a sample of young children with Type 1 DM.Seventy primary caregivers of children (age 3-9 years) with Type 1 DM were recruited and surveyed at diabetes outpatient clinic visits. Patients' medical histories were obtained by medical chart review.Parental diabetes related numeracy (r=-.52, p<01), but not reading skills (r=-.25, p=NS) were inversely correlated with the child's glycemic control (HbA1c). Parental perceived diabetes self-efficacy was also negatively correlated to their child's HbA1c (r=-.47, p<01). When numeracy and parental perceived diabetes self-efficacy were included as predictors of HbA1c, the model was significant (F=12.93, p<.01) with both numeracy (β=-.46, p<.01) and parental perceived diabetes self-efficacy (β=-.36, p=.01) as significant predictors of HbA1c.Data from this study highlight the importance of considering the role of parental numeracy, in health outcomes for children with Type 1 DM.Practitioners should assess parental health literacy and consider intervention when needed.

    View details for DOI 10.1016/j.pec.2013.09.002

    View details for Web of Science ID 000329887300010

    View details for PubMedID 24091252

  • Association between medical home characteristics and staff professional experiences in pediatric practices. Archives of public health = Archives belges de santé publique Knapp, C., Chakravorty, S., Madden, V., Baron-Lee, J., Gubernick, R., Kairys, S., Pelaez-Velez, C., Sanders, L. M., Thompson, L. 2014; 72 (1): 36-?


    The patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature.Eligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware's seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice's medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%.Staff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b = 0.75) and community outreach is negatively associated (b = -0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR = 1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR = 0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout.Staff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale.

    View details for DOI 10.1186/2049-3258-72-36

    View details for PubMedID 25364502

  • Family, community and clinic collaboration to treat overweight and obese children: Stanford GOALS-A randomized controlled trial of a three-year, multi-component, multi-level, multi-setting intervention. Contemporary clinical trials Robinson, T. N., Matheson, D., Desai, M., Wilson, D. M., Weintraub, D. L., Haskell, W. L., McClain, A., McClure, S., A Banda, J., Sanders, L. M., Haydel, K. F., Killen, J. D. 2013; 36 (2): 421-435


    To test the effects of a three-year, community-based, multi-component, multi-level, multi-setting (MMM) approach for treating overweight and obese children.Two-arm, parallel group, randomized controlled trial with measures at baseline, 12, 24, and 36months after randomization.Seven through eleven year old, overweight and obese children (BMI≥85th percentile) and their parents/caregivers recruited from community locations in low-income, primarily Latino neighborhoods in Northern California.Families are randomized to the MMM intervention versus a community health education active-placebo comparison intervention. Interventions last for three years for each participant. The MMM intervention includes a community-based after school team sports program designed specifically for overweight and obese children, a home-based family intervention to reduce screen time, alter the home food/eating environment, and promote self-regulatory skills for eating and activity behavior change, and a primary care behavioral counseling intervention linked to the community and home interventions. The active-placebo comparison intervention includes semi-annual health education home visits, monthly health education newsletters for children and for parents/guardians, and a series of community-based health education events for families.Body mass index trajectory over the three-year study. Secondary outcome measures include waist circumference, triceps skinfold thickness, accelerometer-measured physical activity, 24-hour dietary recalls, screen time and other sedentary behaviors, blood pressure, fasting lipids, glucose, insulin, hemoglobin A1c, C-reactive protein, alanine aminotransferase, and psychosocial measures.The Stanford GOALS trial is testing the efficacy of a novel community-based multi-component, multi-level, multi-setting treatment for childhood overweight and obesity in low-income, Latino families.

    View details for DOI 10.1016/j.cct.2013.09.001

    View details for PubMedID 24028942

  • Impact of specific medical interventions in early childhood on increasing the prevalence of later intellectual disability. JAMA pediatrics Brosco, J. P., Sanders, L. M., Dowling, M., Guez, G. 2013; 167 (6): 544-548


    For the past 100 years, medicine in industrialized nations has become increasingly focused on specific medical interventions designed to improve the health of individual patients. Substantial evidence suggests that broader improvements in public health, nutrition, and economic well-being are more salient than medical or surgical interventions for the remarkable decrease in infant and child deaths since 1900. Less is known about the impact of specific medical interventions on morbidity such as intellectual disability (ID).To explore the impact of medical interventions in early childhood on increasing the prevalence of later ID, as reported in the literature from 1950 through 2000.We reviewed the medical literature and other data from 1950 through 2000 to construct estimates of the condition-specific prevalence of ID over time. We further explored the existing literature to document historically relevant influences on condition-specific prevalence, including the introduction of effective interventions, the timing of these introductions, and the likelihood of their widespread use.Twentieth century United States and Western Europe.Populations of children who received a life-saving intervention within the first 5 years of life and were evaluated for ID after 5 years of age.Case-specific prevalence of ID from 1950 through 2000.Low birth weight is associated with approximately 10% to 15% of the total prevalence of ID. No other new medical therapies introduced during this period were associated with a clinically significant increase in ID prevalence.Previous research has shown that specific medical interventions, such as newborn screening for congenital thyroid deficiency and phenylketonuria, have decreased the prevalence of ID approximately 16% in the United States since 1950. These results suggest that other medical interventions, particularly the advent of intensive care technologies, have also increased the prevalence of ID.

    View details for DOI 10.1001/jamapediatrics.2013.1379

    View details for PubMedID 23699900

  • The Association of Acculturation and Health Literacy, Numeracy and Health-Related Skills in Spanish-speaking Caregivers of Young Children JOURNAL OF IMMIGRANT AND MINORITY HEALTH Ciampa, P. J., White, R. O., Perrin, E. M., Yin, H. S., Sanders, L. M., Gayle, E. A., Rothman, R. L. 2013; 15 (3): 492-498


    Little is known about the relationship among acculturation, literacy, and health skills in Latino caregivers of young children. Latino caregivers of children < 30 months seeking primary care at four medical centers were administered measures of acculturation (SASH), functional health literacy (STOFHLA), numeracy (WRAT-3) and health-related skills (PHLAT Spanish). Child anthropomorphics and immunization status were ascertained by chart review. Caregivers (N = 184) with a median age of 27 years (IQR: 23-32) participated; 89.1% were mothers, and 97.1% had low acculturation. Lower SASH scores were significantly correlated (P < 0.01) with lower STOFHLA (ρ = 0.21), WRAT-3 (ρ = 0.25), and PHLAT Spanish scores (ρ = 0.34). SASH scores predicted PHLAT Spanish scores in a multivariable linear regression model that adjusted for the age of child, the age and gender of the caregiver, number of children in the family, the type of health insurance of the caregiver, and study site (adjusted β: 0.84, 95% CI 0.26-1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted β: 0.66, 95% CI 0.11-1.21, P = 0.02) or numeracy (adjusted β: 0.50, 95% CI -0.04-1.04, P = 0.07) into the model. There was no significant association between acculturation and up-to-date child immunizations or a weight status of overweight/obese. Lower acculturation was associated with worse health literacy and diminished ability to perform child health-related skills. Literacy and numeracy skills attenuated the association between acculturation and child health skills. These associations may help to explain some child health disparities in Latino communities.

    View details for DOI 10.1007/s10903-012-9613-7

    View details for Web of Science ID 000321240400006

    View details for PubMedID 22481307

  • Use of Farmers Markets by Mothers of WIC Recipients, Miami-Dade County, Florida, 2011 PREVENTING CHRONIC DISEASE Grin, B. M., Gayle, T. L., Saravia, D. C., Sanders, L. M. 2013; 10


    Farmers market-based interventions, including the Farmers' Market Nutrition Program of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), represent a promising strategy for improving dietary behaviors in low-income communities. Little is known, however, about the health-related characteristics of low-income parents who frequent farmers markets in urban settings. The objective of this study was to examine the relationship between family-health factors and the use of farmers markets by mothers of WIC recipients.We recruited a convenience sample of mothers of children seeking care at a primary care clinic in a large urban public hospital in Miami, Florida, in 2011 (n = 181 total). The clinic was adjacent to a newly established farmers market at the hospital. Each mother completed an interviewer-administered survey that included self-reported measures of maternal and child health, acculturation, dietary behaviors, food insecurity, and use of farmers markets.Reported use of farmers markets was independently associated with maternal history of diabetes (odds ratio [OR], 6.9; 95% confidence interval [CI], 1.3-38.3) and increased maternal vegetable (but not fruit) consumption (OR, 3.5; 95% CI, 1.5-8.1). Intended future use of farmers markets was independently associated with being unemployed (OR, 2.4; 95% CI, 1.0-5.7), increased maternal vegetable consumption (OR, 2.5; 95% CI, 1.1-5.7), and food insecurity (OR, 3.6; 95% CI, 1.3-10.3).This study provides a snapshot of factors associated with farmers market use in a diverse population of urban low-income families. Understanding these factors may inform public health approaches to increase fresh fruit and vegetable consumption in communities at high risk for preventable chronic conditions.

    View details for DOI 10.5888/pcd10.120178

    View details for Web of Science ID 000329391900005

    View details for PubMedID 23764344

  • CARDIOVASCULAR SURGERY FOR ADULT CONGENITAL HEART DISEASE: VARIATION IN USE OF SPECIALTY-CARE CENTERS 62nd Annual Scientific Session of the American-College-of-Cardiology Fernandes, S. M., Chamberlain, L., Grady, S., Mayo, J., Optowsky, A., Sanders, L. M., Wise, P. H. ELSEVIER SCIENCE INC. 2013: E506–E506
  • Health Literacy Assessment of Labeling of Pediatric Nonprescription Medications: Examination of Characteristics that May Impair Parent Understanding ACADEMIC PEDIATRICS Yin, H. S., Parker, R. M., Wolf, M. S., Mendelsohn, A. L., Sanders, L. M., Vivar, K. L., Carney, K., Cerra, M. E., Dreyer, B. P. 2012; 12 (4): 288-296


    Poor quality and variability of medication labeling have been cited as key contributors to medication misuse. We assessed the format and content of labels and materials packaged with common pediatric liquid nonprescription medications.Descriptive study. A total of 200 top-selling pediatric oral liquid nonprescription medications (during the 52 weeks ending October 30, 2009) categorized as analgesic, cough/cold, allergy, and gastrointestinal products, with dosing information for children <12 years (representing 99% of U.S. market for these products) were reviewed. The principal display panel (PDP) and FDA Drug Facts panel (side panel) of each bottle, and associated box, if present, were independently examined by 2 abstractors. Outcome measures were content and format of active ingredient information and dosing instructions of the principal display panel and Drug Facts panel.Although almost all products listed active ingredients on the Drug Facts panel (side panel), nearly 1 in 5 (37 [18.5%]) did not list active ingredients on the PDP. When present, mean (SD) font size for PDP active ingredients was 10.7 (5.0), smaller than product brand name (32.1 [15.0]) and flavor (13.1 [4.8]); P < .001. Most products included directions in chart form (bottle: 167 [83.5%], box: 148 [96.1%], P < .001); mean (SD) font size: 5.5 (0.9; bottle), 6.5 (0.5; box), P < .001. Few products expressed dosing instructions in pictographic form: 4 (2.6%) boxes and 0 bottles. Nearly all products included the Food and Drug Administration-mandated sections.The format and content of labels for nonprescription pediatric liquid medications could be improved to facilitate parent understanding of key medication information, including active ingredient information and dosing instructions.

    View details for Web of Science ID 000306620200008

    View details for PubMedID 22579032

  • Assessment of Health Literacy and Numeracy Among Spanish-Speaking Parents of Young Children: Validation of the Spanish Parental Health Literacy Activities Test (PHLAT Spanish) ACADEMIC PEDIATRICS Yin, H. S., Sanders, L. M., Rothman, R. L., Mendelsohn, A. L., Dreyer, B. P., White, R. O., Finkle, J. P., Prendes, S., Perrin, E. M. 2012; 12 (1): 68-74


    To assess the health literacy and numeracy skills of Spanish-speaking parents of young children and to validate a new Spanish language health literacy assessment for parents, the Spanish Parental Health Literacy Activities Test (PHLAT Spanish).Cross-sectional study of Spanish-speaking caregivers of young children (<30 months) enrolled at primary care clinics in 4 academic medical centers. Caregivers were administered the 10-item PHLAT in addition to validated tests of health literacy (S-TOFHLA) and numeracy (WRAT-3 Arithmetic). Psychometric analysis was used to examine item characteristics of the PHLAT-10 Spanish, to assess its correlation with sociodemographics and performance on literacy/numeracy assessments, and to generate a shorter 8-item scale (PHLAT-8).Of 176 caregivers, 77% had adequate health literacy (S-TOFHLA), whereas only 0.6% had 9th grade or greater numeracy skills. Mean PHLAT-10 score was 41.6% (SD 21.1). Fewer than one-half (45.5%) were able to read a liquid antibiotic prescription label and demonstrate how much medication to administer within an oral syringe. Less than one-third (31.8%) were able to interpret a food label to determine whether it met WIC (Special supplemental nutrition program for Women, Infants, and Children) guidelines. Greater PHLAT-10 score was associated with greater years of education (r = 0.49), S-TOFHLA (r = 0.53), and WRAT-3 (r = 0.55) scores (P < .001). Internal reliability was good (Kuder-Richardson coefficient of reliability; KR-20 = 0.61). An 8-item scale was highly correlated with the full 10-item scale (r = 0.97, P < .001), with comparable internal reliability (KR-20 = 0.64).Many Spanish-speaking parents have difficulty performing health-related literacy and numeracy tasks. The Spanish PHLAT demonstrates good psychometric characteristics and may be useful for identifying parents who would benefit from receiving low-literacy child health information.

    View details for Web of Science ID 000299361000012

    View details for PubMedID 22056223

  • Mammography Result Notification Letters: Are They Easy to Read and Understand? JOURNAL OF WOMENS HEALTH Marcus, E. N., Sanders, L. M., Pereyra, M., Del Toro, Y., Romilly, A. P., Yepes, M., Hooper, M. W., Jones, B. A. 2011; 20 (4): 545-551


    Federal law mandates that mammography centers notify women of their result in writing. The purpose of this study is to assess the readability and ease of use of the sample letters provided as a template for the notification letters centers send to patients.This is a cross-sectional analysis of the 43 mammography result notification template letters available from the American College of Radiology and two leading transcription software services. To assess readability, we used the Flesch-Kincaid grade level scale and the Lexile framework. To assess document suitability, we used the Suitability Assessment of Materials (SAM). Acceptable scores were based on established standards: ≤6th grade for the Flesch-Kincaid level, ≤900 for the Lexile analysis, and ≥40% on the SAM scale. Means, standard deviations (SDs), and ranges were calculated by diagnostic category, as indicated by BI-RADS level. The Kruskal-Wallis test was used to assess differences in readability and suitability by diagnostic category.The Flesch Kincaid score ranged from 7.7 to 13.5, with a mean of 10.2. The Lexile score ranged from 880 to 1270, with a mean of 1113. The mean SAM score ranged from 16% to 36%, with a mean of 29%. Mean grade level, Lexile score, and SAM score did not vary significantly by diagnostic category. No single document had an acceptable suitability score, and only two had acceptable Lexile scores. Common deficiencies included use of the passive voice, vague wording, and technical jargon.The letters we analyzed were written at levels too difficult for many patients to understand. Future investigations should explore clearer ways of communicating mammography results.

    View details for DOI 10.1089/jwh.2010.2330

    View details for Web of Science ID 000289460400006

    View details for PubMedID 21428738

  • Evaluation of Consistency in Dosing Directions and Measuring Devices for Pediatric Nonprescription Liquid Medications JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Yin, H. S., Wolf, M. S., Dreyer, B. P., Sanders, L. M., Parker, R. M. 2010; 304 (23): 2595-2602


    In response to reports of unintentional drug overdoses among children given over-the-counter (OTC) liquid medications, in November 2009 the US Food and Drug Administration (FDA) released new voluntary industry guidelines that recommend greater consistency and clarity in OTC medication dosing directions and their accompanying measuring devices.To determine the prevalence of inconsistent dosing directions and measuring devices among popular pediatric OTC medications at the time the FDA's guidance was released.Descriptive study of 200 top-selling pediatric oral liquid OTC medications during the 52 weeks ending October 30, 2009. Sample represents 99% of the US market of analgesic, cough/cold, allergy, and gastrointestinal OTC oral liquid products with dosing information for children younger than 12 years.Inclusion of measuring device, within-product inconsistency between dosing directions on the bottle's label and dose markings on enclosed measuring device, across-product use of nonstandard units and abbreviations, and presence of abbreviation definitions.Measuring devices were packaged with 148 of 200 products (74.0%). Within this subset of 148 products, inconsistencies between the medication's dosing directions and markings on the device were found in 146 cases (98.6%). These included missing markings (n = 36, 24.3%) and superfluous markings (n = 120, 81.1%). Across all products, 11 (5.5%) used atypical units of measurement (eg, drams, cc) for doses listed. Milliliter, teaspoon, and tablespoon units were used for doses in 143 (71.5%), 155 (77.5%), and 37 (18.5%) products, respectively. A nonstandard abbreviation for milliliter (not mL) was used by 97 products. Of the products that included an abbreviation, 163 did not define at least 1 abbreviation.At the time the FDA released its new guidance, top-selling pediatric OTC liquid medications contained highly variable and inconsistent dosing directions and measuring devices.

    View details for DOI 10.1001/jama.2010.1797

    View details for Web of Science ID 000285303400022

    View details for PubMedID 21119074

  • Interventions Aimed at Decreasing Obesity in Children Younger Than 2 Years A Systematic Review ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Ciampa, P. J., Kumar, D., Barkin, S. L., Sanders, L. M., Yin, H. S., Perrin, E. M., Rothman, R. L. 2010; 164 (12): 1098-1104


    To assess the evidence for interventions designed to prevent or reduce overweight and obesity in children younger than 2 years.MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and references from relevant articles.Included were published studies that evaluated an intervention designed to prevent or reduce overweight or obesity in children younger than 2 years.Extracted from eligible studies were measured outcomes, including changes in child weight status, dietary intake, and physical activity and parental attitudes and knowledge about nutrition. Studies were assessed for scientific quality using standard criteria, with an assigned quality score ranging from 0.00 to 2.00 (0.00-0.99 is poor, 1.00-1.49 is fair, and 1.50-2.00 is good).We retrieved 1557 citations; 38 articles were reviewed, and 12 articles representing 10 studies met study inclusion criteria. Eight studies used educational interventions to promote dietary behaviors, and 2 studies used a combination of nutrition education and physical activity. Study settings included home (n = 2), clinic (n = 3), classroom (n = 4), or a combination (n = 1). Intervention durations were generally less than 6 months and had modest success in affecting measures, such as dietary intake and parental attitudes and knowledge about nutrition. No intervention improved child weight status. Studies were of poor or fair quality (median quality score, 0.86; range, 0.28-1.43).Few published studies attempted to intervene among children younger than 2 years to prevent or reduce obesity. Limited evidence suggests that interventions may improve dietary intake and parental attitudes and knowledge about nutrition for children in this age group. For clinically important and sustainable effect, future research should focus on designing rigorous interventions that target young children and their families.

    View details for Web of Science ID 000285009900008

    View details for PubMedID 21135337

  • No Follow-Up After Positive Newborn Screening: Medical Neglect? CHILD MALTREATMENT Merrick, M. T., Butt, S. M., Jent, J. F., Cano, N. M., Lambert, W. F., Chapman, A. V., Griffith, J. F., Ciener, D., Dandes, S. K., Sanders, L. M. 2010; 15 (4): 315-323


    The current study examined medical professionals' behaviors related to reporting medical neglect when a family is noncompliant with follow-up services after a positive newborn screening result. Pediatric medical professionals within an urban medical campus were provided with five case vignettes in relation to different diseases. Medical professionals rated the severity of family noncompliance with follow-up services and indicated whether they would report suspected medical neglect to Child Protective Services (CPS). Physicians were more likely to report medical neglect than the other mandated reporters in the study. Logistic regression analyses found that medical professionals' perceptions of the severity of family noncompliance with services were significantly predictive of decisions to report medical neglect. Respondent gender and the method by which families were notified of screening results also significantly affected reporting behaviors in certain instances. Although all vignettes included information that met legal statutes for reporting neglect, medical professionals indicated that they would only report neglect 40-61% of the time across vignettes. Continued investigation of the rationale behind medical professionals' decision-making process and training protocols designed to improve mandated reporter knowledge and reporting behaviors are needed to further reduce bias and improve objectivity when considering ethical and professional obligations to report medical neglect.

    View details for DOI 10.1177/1077559510384983

    View details for Web of Science ID 000282636800005

    View details for PubMedID 20930180

  • Parental Understanding of Infant Health Information: Health Literacy, Numeracy, and the Parental Health Literacy Activities Test (PHLAT) ACADEMIC PEDIATRICS Kumar, D., Sanders, L., Perrin, E. M., Lokker, N., Patterson, B., Gunn, V., Finkle, J., Franco, V., Choi, L., Rothman, R. L. 2010; 10 (5): 309-316


    To assess parental health literacy and numeracy skills in understanding instructions for caring for young children, and to develop and validate a new parental health literacy scale, the Parental Health Literacy Activities Test (PHLAT).Caregivers of infants (age <13 months) were recruited in a cross-sectional study at pediatric clinics at 3 academic medical centers. Literacy and numeracy skills were assessed with previously validated instruments. Parental health literacy was assessed with the new 20-item PHLAT. Psychometric analyses were performed to assess item characteristics and to generate a shortened, 10-item version (PHLAT-10).A total of 182 caregivers were recruited. Although 99% had adequate literacy skills, only 17% had better than ninth-grade numeracy skills. Mean score on the PHLAT was 68% (standard deviation 18); for example, only 47% of caregivers could correctly describe how to mix infant formula from concentrate, and only 69% could interpret a digital thermometer to determine whether an infant had a fever. Higher performance on the PHLAT was significantly correlated (P < .001) with education, literacy skill, and numeracy level (r = 0.29, 0.38, and 0.55 respectively). Caregivers with higher PHLAT scores were also more likely to interpret age recommendations for cold medications correctly (odds ratio 1.6, 95% confidence interval 1.02, 2.6). Internal reliability on the PHLAT was good (Kuder-Richardson coefficient of reliability = 0.76). The PHLAT-10 also demonstrated good validity and reliability.Many parents do not understand common health information required to care for their infants. The PHLAT and PHLAT-10 have good reliability and validity and may be useful tools for identifying parents who need better communication of health-related instructions.

    View details for Web of Science ID 000282109700007

    View details for PubMedID 20674532

  • The Lure of Treatment: Expanded Newborn Screening and the Curious Case of Histidinemia PEDIATRICS Brosco, J. P., Sanders, L. M., Dharia, R., Guez, G., Feudtner, C. 2010; 125 (3): 417-419

    View details for DOI 10.1542/peds.2009-2060

    View details for Web of Science ID 000275945700001

    View details for PubMedID 20156889

  • Historical Trends in Low Birth Weight ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Brosco, J. P., Sanders, L. M., Guez, G., Lantos, J. D. 2010; 164 (1): 99-100

    View details for Web of Science ID 000273262900016

    View details for PubMedID 20048251

  • Pediatricians and health literacy: descriptive results from a national survey. Pediatrics Turner, T., Cull, W. L., Bayldon, B., Klass, P., Sanders, L. M., Frintner, M. P., Abrams, M. A., Dreyer, B. 2009; 124: S299-305


    To describe pediatricians' self-reported experiences with health literacy, use of basic and enhanced communication techniques, and perceived barriers to effective communication during office visits.A national, random sample of 1605 nonretired, posttraining American Academy of Pediatrics members were surveyed in 2007 about health literacy and patient communication as part of the Periodic Survey of Fellows. The response rate was 56% (N = 900).Eight-one percent of the pediatricians were aware of a situation in the previous 12 months in which a parent had not sufficiently understood health information that had been delivered to him or her. In addition, 44% of all pediatricians were aware of a communication-related error in patient care within the previous 12 months. Using simple language (99%), repeating key information (92%), and presenting only 2 or 3 concepts at a time (76%) were the most commonly used communication strategies. Enhanced communication techniques recommended by health literacy experts such as teach-back and indicating key points on written educational materials were used less often (23% and 28%, respectively). The most common reported barriers to effective communication were limited time to discuss information (73%), volume of information (65%), and complexity of information (64%). The majority of physicians rated themselves highly in their ability to identify caregiver understanding (64%), but only 21% rated themselves as very good or excellent in identifying a parent with a literacy problem. Fifty-seven percent of the respondents were interested in training to improve communication skills, and 58% reported that they would be very likely to use easy-to-read written materials, if available from the American Academy of Pediatrics.Pediatricians are aware of health literacy-related problems and the need for good communication with families but struggle with time demands to implement these skills. Despite awareness of communication-related errors in patient care, pediatricians report underutilizing enhanced techniques known to improve communication.

    View details for DOI 10.1542/peds.2009-1162F

    View details for PubMedID 19861484

  • The health literacy of parents in the United States: a nationally representative study. Pediatrics Yin, H. S., Johnson, M., Mendelsohn, A. L., Abrams, M. A., Sanders, L. M., Dreyer, B. P. 2009; 124: S289-98


    To assess the health literacy of US parents and explore the role of health literacy in mediating child health disparities.A cross-sectional study was performed for a nationally representative sample of US parents from the 2003 National Assessment of Adult Literacy. Parent performance on 13 child health-related tasks was assessed by simple weighted analyses. Logistic regression analyses were performed to describe factors associated with low parent health literacy and to explore the relationship between health literacy and self-reported child health insurance status, difficulty understanding over-the-counter medication labeling, and use of food labels.More than 6100 parents made up the sample (representing 72600098 US parents); 28.7% of the parents had below-basic/basic health literacy, 68.4% were unable to enter names and birth dates correctly on a health insurance form, 65.9% were unable to calculate the annual cost of a health insurance policy on the basis of family size, and 46.4% were unable to perform at least 1 of 2 medication-related tasks. Parents with below-basic health literacy were more likely to have a child without health insurance in their household (adjusted odds ratio: 2.4 [95% confidence interval: 1.1-4.9]) compared with parents with proficient health literacy. Parents with below-basic health literacy had 3.4 times the odds (95% confidence interval: 1.6-7.4) of reporting difficulty understanding over-the-counter medication labels. Parent health literacy was associated with nutrition label use in unadjusted analyses but did not retain significance in multivariate analyses. Health literacy accounted for some of the effect of education, racial/ethnic, immigrant-status, linguistic, and income-related disparities.A large proportion of US parents have limited health-literacy skills. Decreasing literacy demands on parents, including simplification of health insurance and other medical forms, as well as medication and food labels, is needed to decrease health care access barriers for children and allow for informed parent decision-making. Addressing low parent health literacy may ameliorate existing child health disparities.

    View details for DOI 10.1542/peds.2009-1162E

    View details for PubMedID 19861483

  • Health literacy and child health promotion: implications for research, clinical care, and public policy. Pediatrics Sanders, L. M., Shaw, J. S., Guez, G., Baur, C., Rudd, R. 2009; 124: S306-14


    The nation's leading sources of morbidity and health disparities (eg, preterm birth, obesity, chronic lung disease, cardiovascular disease, type 2 diabetes, mental health disorders, and cancer) require an evidence-based approach to the delivery of effective preventive care across the life course (eg, prenatal care, primary preventive care, immunizations, physical activity, nutrition, smoking cessation, and early diagnostic screening). Health literacy may be a critical and modifiable factor for improving preventive care and reducing health disparities. Recent studies among adults have established an independent association between lower health literacy and poorer understanding of preventive care information and poor access to preventive care services. Children of parents with higher literacy skills are more likely to have better outcomes in child health promotion and disease prevention. Adult studies in disease prevention have suggested that addressing health literacy would be an efficacious strategy for reducing health disparities. Future initiatives to reduce child health inequities should include health-promotion strategies that meet the health literacy needs of children, adolescents, and their caregivers.

    View details for DOI 10.1542/peds.2009-1162G

    View details for PubMedID 19861485

  • Parental Misinterpretations of Over-the-Counter Pediatric Cough and Cold Medication Labels PEDIATRICS Lokker, N., Sanders, L., Perrin, E. M., Kumar, D., Finkle, J., Franco, V., Choi, L., Johnston, P. E., Rothman, R. L. 2009; 123 (6): 1464-1471


    Concerns about the safety and efficacy of over-the-counter cold medications have led to a recent US Food and Drug Administration public health advisory against their use in children <2 years of age. Our goal was to examine caregiver understanding of the age indication of over-the-counter cold medication labels and identify factors, associated with caregiver understanding.Caregivers of infant children (< or =1 year old) were recruited from clinics at 3 institutions. Questions were administered regarding the use of 4 previously common "infant" over-the-counter cold and cough medicines labeled to consult a physician if used in children <2 years of age. Literacy and numeracy skills were assessed with validated instruments.A total of 182 caregivers were recruited; 87% were the infants' mothers. Mean education level was 12.5 years, and 99% had adequate literacy skills, but only 17% had >9th-grade numeracy skills. When examining the front of the product label, 86% of the time parents thought these products were appropriate for use in children <2 years of age. More than 50% of the time, parents stated they would give these over-the-counter products to a 13-month-old child with cold symptoms. Common factors that influenced parental decisions included label saying "infant," graphics (eg, infants, teddy bears, droppers), and dosing directions. Caregivers were influenced by the dosing directions only 47% of the time. Caregivers with lower numeracy skills were more likely to provide inappropriate reasons for giving an over-the-counter medication.Misunderstanding of over-the-counter cold products is common and could result in harm if medications are given inappropriately. Label language and graphics seem to influence inappropriate interpretation of over-the-counter product age indications. Poorer parental numeracy skills may increase the misinterpretation of these products. Opportunities exist for the Food and Drug Administration and manufacturers to revise existing labels to improve parental comprehension and enhance child safety.

    View details for DOI 10.1542/peds.2008-0854

    View details for Web of Science ID 000266319000004

    View details for PubMedID 19482755

  • Literacy and Child Health A Systematic Review ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Sanders, L. M., Federico, S., Klass, P., Abrams, M. A., Dreyer, B. 2009; 163 (2): 131-140


    To assess the prevalence of low health literacy among adolescents, young adults, and child caregivers in the United States, the readability of common child-health information, and the relationship between literacy and child health.MedLine, Educational Resources Information Center, National Library of Medicine, PsychInfo, Harvard Health Literacy Bibliography, and peer-reviewed abstracts from the Pediatric Academic Societies Annual Meetings.A systematic review using the following key words: health literacy, literacy, reading skill, numeracy, and Wide Range Achievement Test.Descriptive studies that used at least 1 valid measure of health literacy, studies that assessed the readability of child health information, and observational or experimental studies that included a validated measure of health literacy, literacy, or numeracy skills and an assessment of child health-related outcomes.A total of 1267 articles were reviewed, and 215 met inclusion and exclusion criteria. At least 1 in 3 adolescents and young adults had low health literacy; most child health information was written above the tenth-grade level. Adjusted for socioeconomic status, adults with low literacy are 1.2 to 4 times more likely to exhibit negative health behaviors that affect child health, adolescents with low literacy are at least twice as likely to exhibit aggressive or antisocial behavior, and chronically ill children who have caregivers with low literacy are twice as likely to use more health services.Low caregiver literacy is common and is associated with poor preventive care behaviors and poor child health outcomes. Future research should aim to ameliorate literacy-associated child health disparities.

    View details for Web of Science ID 000262991800006

    View details for PubMedID 19188645

  • A Prospective Study of Weight and Metabolic Syndrome in Young Hispanic Children CHILDRENS HEALTH CARE Patino-Fernandez, A. M., Delamater, A. M., Sanders, L., Brito, A., Goldberg, R. 2008; 37 (4): 316-332
  • Conduct disorder. Pediatrics in review Sanders, L. M., Schaechter, J., Serwint, J. R. 2007; 28 (11): 433-434

    View details for PubMedID 17974708

  • Factors influencing community pediatrics training in residency Annual Meeting of the Pediatric-Academic-Societies/Society-of-Pediatric-Research Minkovitz, C. S., Chandra, A., Solomon, B. S., Sanders, L. M., Grason, H. A., Carraccio, C. MOSBY-ELSEVIER. 2007: 119–20

    View details for DOI 10.1016/j.jpeds.2006.10.047

    View details for Web of Science ID 000244111300001

    View details for PubMedID 17236883

  • Caregiver health literacy and the use of child health services PEDIATRICS Sanders, L. M., Thompson, V. T., Wilkinson, J. D. 2007; 119 (1): E86-E92


    Eighty million US adults have low health literacy, a risk factor for increased health care use among adults. The purpose of this work was to assess the association between caregiver health literacy and the use and cost of child health services.We conducted a cross-sectional study of caregiver-child dyads from a sample of children aged 12 months to 12 years presenting to the pediatric emergency department of an urban, public hospital. Caregiver health literacy was measured by the Short Test of Functional Health Literacy in their preferred language (English or Spanish). Child health care use was measured by a 12-month retrospective review of the public hospital system's electronic database and of state Medicaid billing records for 4 types of visits: preventive care, urgent care, emergency care, and hospital care. Cost of child health care use was provided by Medicaid billing records. Multivariate analysis included caregiver education, age, and language proficiency, as well as child age, special health care needs, ethnicity, and health-insurance coverage.A total of 290 dyads were enrolled in the study. Twenty-two percent of caregivers had low (inadequate or marginal) health literacy. Caregivers with low health literacy were more likely to have less than a high school education, to have limited English proficiency, and to have been born outside the United States. There were no differences in health care use or cost between children of caregivers with low health literacy and children of caregivers with adequate health literacy. Three caregiver characteristics were associated with increased use of child health care services: born outside the United States, age at child's birth <24 years, and limited English proficiency.One in 5 caregivers of young children has low health literacy. Caregiver health literacy, however, was not associated with disparities in the use of child health services in this inner-city, ethnic minority population.

    View details for DOI 10.1542/peds.2005-1738

    View details for Web of Science ID 000243191800013

    View details for PubMedID 17200263

  • Pediatric residents' perceptions of community involvement prior to residency AMBULATORY PEDIATRICS Solomon, B. S., Blaschke, G. S., West, D. C., Pan, R. J., Sanders, L., Swigonski, N., Willis, E., Schwarz, D. 2006; 6 (6): 337-341


    To describe baseline perceptions of first-year pediatric residents of participating in community activities, to determine whether demographic factors are related to perceived benefits and constraints, and to identify factors associated with expected community involvement.Pediatric residents beginning their training in the fall of 2000 to 2003 participated in a 12-item self-administered written survey as part of the national evaluation of the Dyson Community Pediatrics Training Initiative.Of the 612 first-year residents surveyed (90% response rate), most reported they receive personal satisfaction (92%) and gain valuable skills and knowledge (83%) from their involvement in community activities. Less than a quarter felt peer support and professional recognition were benefits. Almost two thirds reported logistics and lost personal time as constraints to community involvement. Compared with their colleagues, older residents (> 29 years) and underrepresented minority residents reported fewer constraints. Most residents (72%) expect moderate to substantial involvement in community activities after graduating. Those expecting greater involvement were more likely to report personal satisfaction, gaining valuable skills and knowledge, peer support, and the opportunity to spend time with like-minded peers as benefits.Pediatric residents beginning their postgraduate training perceive numerous benefits from their participation in community activities and most expect a moderate degree of future community involvement. Residency directors should: 1) consider their trainees' insights from prior community involvement and 2) integrate meaningful community experiences in ways that confront logistic barriers and time constraints.

    View details for Web of Science ID 000242524200007

    View details for PubMedID 17116607

  • Advocacy by any other name would smell as sweet ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Chamberlain, L. J., Sanders, L. M., Takayama, J. I. 2006; 160 (4): 453-453

    View details for Web of Science ID 000236516500024

    View details for PubMedID 16585499

  • Child advocacy training - Curriculum outcomes and resident satisfaction ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Chamberlain, L. J., Sanders, L. M., Takayama, J. I. 2005; 159 (9): 842-847


    Many health problems affecting children today are based in the community and cannot be easily addressed in the office setting. Child advocacy is an effective approach for pediatricians to take.To describe pediatric residents' choices of advocacy topics and interventions.Cross-sectional observational study.Residents from 3 pediatric training programs participated in the Child Advocacy Curriculum, which featured standardized workshops and the development of individual advocacy projects. To evaluate the curriculum, project descriptions and material products were analyzed to determine individual advocacy topics, topic themes, and targets of project interventions. Differences among programs were assessed. Residents also completed an anonymous questionnaire assessing their experience with the Child Advocacy Curriculum.Residents demonstrated a wide range of interests in selecting advocacy topics: 99 residents chose 38 different topics. The most common topic was obesity (13 residents) followed by health care access (9), teen pregnancy prevention (6), and oral health (5). Themes included health promotion and disease prevention, injury prevention, health care access, children with special health care needs, child development, at-risk populations, and the impact of media on child health. The project interventions targeted the local community most frequently (37%), followed by resident education (27%), hospital systems (21%), and public and health policy (15%). The vast majority of participating residents reported a positive experience with the Child Advocacy Curriculum.The wide range of topics and settings in which residents developed projects illustrates residents' extensive interests and ingenuity in applying needed advocacy solutions to complex child health issues.

    View details for Web of Science ID 000231653800007

    View details for PubMedID 16143743

  • Evidence-based community pediatrics: Building a bridge from bedside to neighborhood PEDIATRICS Sanders, L. M., Robinson, T. N., Forster, L. Q., Plax, K., Brosco, J. P., Brito, A. 2005; 115 (4): 1142-1147


    The American Academy of Pediatrics policy statement "The Pediatrician's Role in Community Pediatrics" encourages all pediatricians to partner with their communities to create and disseminate innovative programs that improve child health. This article describes 4 pillars of a bridge to evidence-based community pediatrics for pediatricians interested in pursuing effective community action: (1) collaborate with the community to establish a specific, short-term, health-related goal; (2) identify evidence-based best practice(s) for achieving the shared goal; (3) collaborate with the community to adapt this best practice to the community's unique assets and constraints; and (4) evaluate the project by using appropriate expertise. Practical elements of each pillar are described and illustrated by specific examples from community-based efforts of pediatricians and are accompanied by specific resources to aid pediatricians in their future community health work.

    View details for DOI 10.1542/peds.2004-2825H

    View details for Web of Science ID 000228108800008

    View details for PubMedID 15821298

  • Number of children's books in the home: An indicator of parent health literacy AMBULATORY PEDIATRICS Sanders, L. M., Zacur, G., Haecker, T., Klass, P. 2004; 4 (5): 424-428


    One in 4 US adults have poor health literacy, unable to read and understand written medical information. Current tools that assess health literacy skills are too lengthy to be useful in routine clinical encounters.To determine which of 7 screening questions is most useful for identifying parents with adequate health literacy.A cross-sectional study of an ethnically diverse sample of 163 parents of children aged 12 to 24 months presenting for routine care at 1 of 6 inner-city clinics. Literacy was measured by performance on the Short Test of Functional Health Literacy for Adults, which was categorized as "adequate" or "inadequate or marginal." The 7 screening questions concerned parents' educational achievement, educational expectations for the child, and home literacy environment.Eighty-three percent of respondents had adequate health literacy, which was highest among those who were African American, were born outside the United States, spoke English primarily at home, and had completed high school. Only 2 factors, however, were independently associated with adequate health literacy: more than 10 adults' books or more than 10 children's books in the home. "More than 10 children's books" had a positive predictive value of 91%.Having more than 10 children's books in the home is a useful, independent indicator of adequate parent health literacy. More research is needed, however, to find a better screening tool for identifying parents with increased health literacy needs.

    View details for Web of Science ID 000224035900006

    View details for PubMedID 15369414

  • Helping Families ImproveSelf-Management of Pediatric Asthma: A Guide for the Primary Care Physician. Pediatric case reviews (Print) Sanders, L. M., McCullough, J. R. 2002; 2 (2): 112-125

    View details for PubMedID 12865688

  • Prescribing books for immigrant children - A pilot study to promote emergent literacy among the children of Hispanic immigrants ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Sanders, L. M., Gershon, T. D., Huffman, L. C., Mendoza, F. S. 2000; 154 (8): 771-777


    To assess book-sharing activities within first-generation Hispanic immigrant families, and to assess the effect of pediatricians giving books to their patients.Survey.Convenience sample of 122 predominantly Hispanic immigrant parents of children aged 2 months to 5 years. Of these parents, 56 had received children's books from the pediatrician, and 66 had not.House staff continuity clinic at a university children's hospital.Frequent Book Sharing (FBS) was defined as a parent's reporting more than 3 days per week of sharing books with the child. Main independent variables included the following: (1) exposure to the Reach Out and Read program, defined as having received a children's book from the pediatrician; (2) socioeconomics, as measured by parents' years of education and Medicaid enrollment; (3) acculturation, as defined by 4 questions relating to parents' proficiency with the English language; (4) parent's country of origin; (5) parent literacy, as measured by a parent's reporting more than 3 days per week of reading alone; (6) parent's age; (7) marital status; (8) household size; (9) child's age; (10) child's sex.Ninety percent of the parents were born outside of the United States (71% in Mexico), 85% spoke Spanish in the home, and 63% had completed less than a high-school education. Seventy-five percent of children's medical insurance was provided by Medi-Cal (Medicaid), and 9% of children were uninsured. Sixty-seven percent spoke exclusively Spanish at home, and 84% of parents want their children to learn to read in both English and Spanish. High FBS was reported among parents whose children had received books from the physician when compared with parents whose children had received no books. The odds ratio (OR) was 3.62 (95% confidence interval [CI], 1.40-9.37; P<.05). Also associated with FBS were parents reading frequently to themselves (OR = 9.52; 95% CI, 2.09-43.27; P<.05) and national origin outside Mexico (OR = 5.54; 95% CI, 1.59-19.27; P<.05). These findings were independent of parent's educational level, parent's employment, parent's age, acculturation, and family size.Pediatricians can promote literacy development among Hispanic immigrant children through the provision of free books at well-child visits. Our findings also suggest the independent effects of adult literacy and child age. Further research is needed to understand the effect of pediatric literacy programs on Hispanic immigrant children, their bilingual environments, and their readiness for school entry. Arch Pediatr Adolesc Med. 2000;154:771-777

    View details for Web of Science ID 000088655000003

    View details for PubMedID 10922272

  • Understanding the practice of ethics consultation: Results of an ethnographic multi-site study JOURNAL OF CLINICAL ETHICS Kelly, S. E., Marshall, P. A., Sanders, L. M., Raffin, T. A., Koenig, B. A. 1997; 8 (2): 136-149

    View details for Web of Science ID A1997XW32500003

    View details for PubMedID 9302631


    View details for Web of Science ID A1994NX37200003

    View details for PubMedID 8020272

  • ETHICS OF FETAL TISSUE-TRANSPLANTATION WESTERN JOURNAL OF MEDICINE Sanders, L. M., Giudice, L., Raffin, T. A. 1993; 159 (3): 400-407


    Now that the Clinton Administration has overturned the ban on federal funding for fetal tissue transplantation, old ethical issues renew their relevance and new ethical issues arise. Is fetal tissue transplantation necessary and beneficial? Are fetal rights violated by the use of fetal tissue in research? Is there a moral danger that the potential of fetal tissue donation will encourage elective abortions? Should pregnant women be allowed to designate specific fetal transplant recipients? What criteria should be used to select fetal tissue transplants? Whose consent should be required for the use of fetal tissue for transplantation? We review the current state of clinical research with fetal tissue transplantation, the legal history of fetal tissue research, the major arguments against the use of fetal tissue for transplantation, and the new postmoratorium ethical dilemmas. We include recommendations for guidelines to govern the medical treatment of fetal tissue in transplantation.

    View details for Web of Science ID A1993MA37000022

    View details for PubMedID 8236984

  • The ethics of withholding and withdrawing critical care. Cambridge quarterly of healthcare ethics Sanders, L. M., Raffin, T. A. 1993; 2 (2): 175-184

    View details for PubMedID 8293207


    View details for Web of Science ID A1992JX20900060

    View details for PubMedID 1424892