'Let mum have her say': turntaking in doctor-parent-child communication

Behavioral Intervention for Adults With Autism on Distribution of Attention in Triadic Conversations: A/B-Tested Pre-Post Study

BACKGROUND

Cross-neurotype differences in social communication patterns contribute to high unemployment rates among adults with autism. Adults with autism can be unsuccessful in job searches or terminated from employment due to mismatches between their social attention behaviors and society's expectations on workplace communication.

OBJECTIVE

We propose a behavioral intervention concerning distribution of attention in triadic (three-way) conversations. Specifically, the objective is to determine whether providing personalized feedback to each individual with autism based on an analysis of their attention distribution behavior during an initial conversation session would cause them to modify their orientation behavior in a subsequent conversation session.

METHODS

Our system uses an unobtrusive head orientation estimation model to track the focus of attention of each individual. Head orientation sequences from a conversation session are analyzed based on five statistical domains (eg, maximum exclusion duration and average contact duration) representing different types of attention distribution behavior. An intervention is provided to a participant if they exceeded the nonautistic average for that behavior by at least 2 SDs. The intervention uses data analysis and video modeling along with a constructive discussion about the targeted behaviors. Twenty-four individuals with autism with no intellectual disabilities participated in the study. The participants were divided into test and control groups of 12 participants each.

RESULTS

Based on their attention distribution behavior in the initial conversation session, 11 of the 12 participants in the test group received an intervention in at least one domain. Of the 11 participants who received the intervention, 10 showed improvement in at least one domain on which they received feedback. Independent t tests for larger test groups (df>15) confirmed that the group improvements are statistically significant compared with the corresponding controls (P<.05). Crawford-Howell t tests confirmed that 78% of the interventions resulted in significant improvements when compared individually against corresponding controls (P<.05). Additional t tests comparing the first conversation sessions of the test and control groups and comparing the first and second conversation sessions of the control group resulted in nonsignificant differences, pointing to the intervention being the main effect behind the behavioral changes displayed by the test group, as opposed to confounding effects or group differences.

CONCLUSIONS

Our proposed behavioral intervention offers a useful framework for practicing social attention behavior in multiparty conversations that are common in social and professional settings.

Child participation during outpatient consultations: a mixed methods study

Although children wish to be included in their own healthcare, they recognize a gap between their right to be heard and their ability to become involved. Despite adaptation of medical consultation styles which suit a more patient-centered approach, data on the current state of child participation in clinical encounters are missing. We aimed to assess actual child participation in a Dutch pediatric clinic. Children aged 4-18 years visiting a pediatric outpatient clinic for consultation after general practitioner's referral were included. Sixteen consultations of six pediatricians were recorded and transcribed verbatim. Quantitative measurement included word count and speech turn; conversation analysis with qualitative appraisal provided data on participatory behavior. Quantitative child participation equaled parent participation in turns (28% vs 29%, respectively), but remained limited in words (relative contribution 11% for child, 23% for parent and 66% for pediatrician). Children spoke on average six words per speech turn. Child age correlated positively with participation in words (p = 0.022, r = 0.566) and turns (p =  < 0.001, r = 0.746). Children were mostly involved during social history taking, introduction, and physical examination but did not actively speak during the decision-making process. Children took an active role by instigating talks. Qualitative facilitators included appropriate language and verbal or non-verbal child allocated turns. Adults involved children by asking them questions and verifying their opinions or plans with the child. Teenagers participated most during the entire consultation, while younger children were more likely to lose their focus by the end of the conversation.

CONCLUSION

Despite increased turn taking, children's verbal participation remains low in pediatric consultations. If pediatricians and parents maintain a triadic conversation style throughout every stage of the medical encounter, child participation may increase.

WHAT IS KNOWN

• Verbal child participation varies between 4 and 17%, measured in turns, words, speech time, or utterances. • Child participation is limited to social talk, laughter, and providing medical information.

WHAT IS NEW

• Child speech turns equal parental speech turns (28%), but average relative word count remains low (11%). • Three percent of the children's turns are defined a "contributing in decision making, giving their opinion or give consent," which equals three turns per consultation.

Adult Children as Companions in Geriatric Consultations: An Interpersonal Perspective from China

Despite the prevalence of accompanied medical visits all over the world, most literature on triadic medical communication shares an Anglo-American background; little is known about non-dyadic medical interactions in Asian societies such as China. This article explores triadic interactions in Chinese geriatric outpatient consultations, focusing on the interpersonal dynamics between doctors, older patients, and the adult children who accompany them throughout the consultation. From an interpersonal pragmatic approach, we conduct a conversation analysis of the transcription of 36 audio-recorded encounters. Our findings demonstrate three patterns of companions' communicative actions during geriatric visits: enhancing rapport, mitigating face threats, and adding tension. These patterns reveal the multi-faceted nature of adult children's participation in geriatric care, highlighting their capacity to simultaneously facilitate a positive interpersonal atmosphere and pose challenges to their older parents' face. Delving into the nuanced mechanisms through which these patterns of engagement are triggered, warranted, and negotiated by all participants in the local contingencies, we further illuminate the institutional and cultural context that informs companions' intervention. Our analysis demonstrates that the influence of Chinese familial values and institutional constraints in Chinese tertiary hospitals, including restricted time and limited privacy within the clinic room, have shaped the interpersonal dynamic in triadic geriatric care. Our research calls for the development of nuanced and targeted interventions and training for healthcare professionals and companions of older patients alike.

Examining Children's Experiences of Visiting Their Pediatrician: Insights into Communication, Actions, and Emotions

The way children experience a medical visit lays the groundwork for their health education and fosters trust and comfort in healthcare relationships. This study employed a retrospective and narrative-based design to analyze how children perceived their experiences of visits to their doctor, how they describe their emotions, and how they portray the different relationships within the doctor-caregiver-patient triad. Three hundred fifty students (50.75% female, 8-13 years, Mage = 10.5, SD = 5.93, 77.95% from primary school) completed a booklet comprising different narrative activities. The booklet underwent quantitative content analysis according to gender and school level. Children reported that the doctors primarily addressed their caregivers when asking for and delivering health-related information, while their role was mostly passive. Meeting with friendly doctors and being in a welcoming environment were associated with a positive medical experience, while negative emotions and encounters with unsympathetic practitioners contributed to negative experiences. Most respondents wanted to talk privately with their doctors at their next visit. Some examples and practices are discussed to enable healthcare practitioners to create an environment where children are heard and valued, and their involvement during consultation processes is enhanced.

Child participation in triadic medical consultations: A scoping review and summary of promotive interventions

OBJECTIVES

To promote patient centered care, children with health issues should be supported to participate in consultations with health care professionals. We aimed to summarize, in a scoping review, the evidence on child participation in triadic encounters and its promotive interventions.

METHODS

Two researchers systematically searched four major databases, and included studies on child participation in medical consultations. A synthesis of quantitative and qualitative data was made.

RESULTS

Of 1678 retrieved records, 39 papers were included: 22 quantitative, 14 qualitative and 3 mixed-methods studies. Child participation, measured by utterances, turns or speech time, ranged between 4% and 14%. Participation increased with age. Equidistant seating arrangements, child-directed gaze and finding the appropriate tone of voice by the physician promoted child participation. Despite all facilitative efforts of doctors and parents, such as social talk, eHealth tools or consultation education, no increase in child participation was observed over the last 50 years.

CONCLUSIONS

Children continue to participate only marginally in medical consultations, despite their desire to be involved in various aspects of the clinical encounter and their right to have their voice heard.

PRACTICE IMPLICATIONS

Health care professionals should provide more opportunities for children to participate in triadic medical encounters and create an inclusive environment.

Mapping PedsQL™ scores to CHU9D utility weights for children with chronic conditions in a multi-ethnic and deprived metropolitan population

PURPOSE

The Child Health Utility-9 Dimensions (CHU9D) is a patient-reported outcome measure to generate Quality-Adjusted Life Years (QALYs), recommended for economic evaluations of interventions to inform funding decisions. When the CHU9D is not available, mapping algorithms offer an opportunity to convert other paediatric instruments, such as the Paediatric Quality of Life Inventory™ (PedsQL), onto the CHU9D scores. This study aims to validate current PedsQL to CHU9D mappings in a sample of children and young people of a wide age range (0 to 16 years of age) and with chronic conditions. New algorithms with improved predictive accuracy are also developed.

METHODS

Data from the Children and Young People's Health Partnership (CYPHP) were used (N = 1735). Four regression models were estimated: ordinal least squared, generalized linear model, beta-binomial and censored least absolute deviations. Standard goodness of fit measures were used for validation and to assess new algorithms.

RESULTS

While previous algorithms perform well, performance can be enhanced. OLS was the best estimation method for the final equations at the total, dimension and item PedsQL scores levels. The CYPHP mapping algorithms include age as an important predictor and more non-linear terms compared with previous work.

CONCLUSION

The new CYPHP mappings are particularly relevant for samples with children and young people with chronic conditions living in deprived and urban settings. Further validation in an external sample is required. Trial registration number NCT03461848; pre-results.

Video-based observation research: A systematic review of studies in outpatient health care settings

OBJECTIVE

To examine the use of video-based observation research in outpatient health care encounter research.

METHODS

We conducted a systematic search of MEDLINE, Scopus, Cochrane and other databases from database inception to October 2020 for reports of studies that used video recording to investigate ambulatory patient-clinician interactions. Two authors independently reviewed all studies for eligibility and extracted information related to study setting and purpose, participant recruitment and consent processes, data collection procedures, method of analysis, and participant sample characteristics.

RESULTS

175 articles were included. Most studies (65%) took place in a primary care or family practice setting. Study objectives were overwhelmingly focused on patient-clinician communication (81%). Reporting of key study elements was inconsistent across included studies.

CONCLUSION

Video recording has been used as a research method in outpatient health care in a limited number and scope of clinical contexts and research domains. In addition, reporting of study design, methodological characteristics, and ethical considerations needs improvement.

PRACTICE IMPLICATIONS

Video recording as a method has been relatively underutilized within many clinical and research contexts. This review will serve as a practical resource for health care researchers as they plan and execute future video-based studies.

Gender and age concordance between patient and GP: an observational study on associations with referral behaviour

BACKGROUND

Appropriate referral from primary to secondary care is essential for maintaining a healthcare system that is accessible and cost-effective. Social concordance can affect the doctor-patient interaction and possibly also referral behaviour.

AIM

To investigate the association of gender concordance and age concordance on referral rates in primary care in The Netherlands.

DESIGN & SETTING

Electronic health records data (n = 24 841) were used from 65 GPs in The Netherlands, containing referral information, which was combined with demographics of GPs and patients to investigate factors associated with referral likelihood.

METHOD

Health records covered 16 different symptoms and diagnoses, categorised as 'gender sensitive', 'age sensitive', 'both age and gender sensitive', or 'neutral' based on Delphi consensus. Multi-level logistic regressions were performed to calculate the associations of gender and age concordance with referral status.

RESULTS

Overall, 16.8% of patients were referred to a medical specialist. The female-male dyad (GP-patient) was associated with a higher referral likelihood (odds ratio [OR] 1.14; 95% confidence interval [CI] = 1.02 to 1.27; P = 0.02) compared with the female-female dyad. Gender discordance was associated with a higher referral likelihood regarding consultations involving 'gender-sensitive' symptoms and diagnoses (OR 1.21; CI = 1.02 to 1.44; P = 0.03), and in duo and group practices (OR 1.08; 95% CI = 1.00 to 1.16; P = 0.05). Age concordance was not a significant predictor of referrals in the main model nor in subgroup analyses.

CONCLUSION

Gender discordance was associated with a higher likelihood of referring. This study adds to the evidence that gender concordance affects decisions to refer, particularly with respect to symptoms and diagnoses that can be regarded as 'gender sensitive'.

Exploring parents' perceptions on the importance and feasibility of child-centred consultations of 5-11 year olds in general practice

BACKGROUND

The active involvement of children in their health care has been shown to increase compliance and improve outcomes. Despite this, children in the 6-12 year group have little meaningful involvement in General Practitioner (GP) consultations, contributing to less than 20% of interactions.

AIM

To explore parents' perceptions on the importance and feasibility of child-centred consultations.

METHODS

Purposive sampling was used to recruit parents from a primary school in London. Three audio recorded focus groups were conducted, transcribed verbatim, and subsequently thematically analysed.

RESULTS

While most parents acknowledged the importance of child-centred consultations, they legitimately questioned their child's ability to make decisions. Parents attributed low child participation to several factors including the perceived approachability of the GP, whether their child had met the doctor before, their child's personality and the general lack of time during consultations. Parents described their own anxiety and worries surrounding their child's health care which lead to their role as their child's advocate, decision maker and protector during GP consultations.

CONCLUSION

This study confirms the importance of child-centred consultations and highlights numerous barriers which need to be overcome to achieve greater child involvement in consultations. If the findings were to be replicated in future larger studies, then it could lead to changes in both training and, crucially, how child-parent-doctor consultations should be carried out in general practice.

Children's Drawing as a Projective Measure to Understand Their Experiences of Dental Treatment under General Anesthesia

PURPOSE

The overall aim of the study was to gain a deeper understanding of 3 to 10 year-old children's experiences, main concerns, and how they manage attending hospital for dental treatment under general anesthesia (DTGA).

METHODS

Twelve children aged 3-10 who were scheduled for DTGA were interviewed. In addition to tape-recorded interviews, data were collected using video diaries, participant observations, and pre-, peri-, and postoperative drawings. The children's drawings (n = 43) were analyzed using the Child Drawing: Hospital Manual (CD:H) and Vygotsky postulations for context readings, with the aim to explore what it means for children to undergo DTGA.

RESULTS

The analysis found that the main concern for children during the pre-operative period was that they were forced to prepare for an unknown experience, which elicited stress. This situation was handled during the peri-operative period by trying to recover control and to cooperate despite fear, stress, and anxiety. Drawings completed post-operatively showed the surgical mask, "stinky" smell of the anesthetic gas, and multiple extraction of teeth were the main troubling experiences for children. Several weeks after DTGA, children tried to regain normalcy in their lives again.

CONCLUSION

This study contributed to a deeper understanding of how children as young as 3 years undergoing DTGA experience and express their lived experiences: emotional, psychological, physiological, or physical stress in the context of DTGA.

Promotion of appropriate knowledge and attitude towards medicines among schoolchildren in Jordan: the role of teachers

OBJECTIVES

The current study aimed to examine the knowledge, attitude and practice of schoolteachers in Jordan towards medication. Furthermore, it assessed teachers' views regarding the importance of school education in the promotion of appropriate and safe use of medicines.

METHODS

All Facebook groups of teachers who were members of the Jordan Teachers Syndicate and/or teachers employed by Jordan Ministry of Education were invited to participate. A cross-sectional online survey using a validated pre-piloted anonymous Arabic questionnaire was created using Google documents. The questionnaire was automatically hosted via a unique URL. Researchers downloaded real-time questionnaire responses. Data were coded and entered into SPSS database for windows version 22 for statistical analysis.

KEY FINDINGS

A total of 902 teachers filled in the questionnaire. The mean knowledge score achieved in multiple-choice questions was 2.43 ± 0.51 out of 4.00. The top three factors affecting all of teachers' knowledge questions were as follows: age, the presence of chronic disease, and the school grade that they taught. Teachers showed variation in their attitude towards education about medicines in children. The majority (80.7%) of teachers were unfamiliar with education about medication and had never taught schoolchildren about any issues related to proper use of medications.

CONCLUSIONS

The study highlighted that teachers' knowledge about medicines was not satisfactory enough for them to become active health educators. At the same time, they were willing to educate children about proper use of medicines, and such education should be started at the first grade (i.e. 6 years old).

Development of an interaction coding scheme (PaeD-TrICS) to record the triadic communication behaviours in preventive dental consultations with preschool child patients and families: a video-based observational study

Background

There is a paucity of research concerning paediatric dental consultations in primary care. This is potentially due to the difficulty of measuring the communication behaviours in the complex triadic consultations. The present study aims to describe the development and refinement of a coding scheme to record the triadic communication between dental professionals, child patients and parents.

Methods

The PaeD-TrICS was developed from video observation of triadic communications and refined through an iterative process. Its practical applicability was assessed via implementation of the scheme on specialised behavioural coding software. Reliability was calculated using Cohen’s Kappa.

Results

The PaeD-TrICS contains 45 codes. Forty-four dental professional-child-parent communications were successfully coded through administering the scheme on The Observer XT 10.5 system. Cohen’s Kappa was 0.83 (inter-coder) and 0.90 (intra-coder). “Parental verbal facilitation” (mean = 1.68/min) was the most frequent behaviour. Dental professionals’ “dentally engaging talk” (mean = 1.24/min), “praise” (mean = 1.10/min) and “instruction” (mean = 0.62/min) were frequently seen. Children’s common behaviours included “speech other” (mean = 0.66/min) and non-verbal behaviour i.e. “non-verbal agreement” and verbal behaviour “speech yes” (mean = 0.26/min).

Conclusions

The PaeD-TrICS is developed to capture the communication behaviour of the triadic consultations in a preventive dental setting. It demonstrates satisfactory intra- and inter-coder reliability and has been successfully used in paediatric dental consultations.

Measuring the health-related quality of life in young children: how far have we come?

The importance of understanding the impact of disease and treatment on children's Health-Related Quality of Life (HRQoL) has given rise to an increasing use of child self-report and observer or proxy instruments. In this article, we review the status quo and challenges of HRQoL measurement specific to children under five. A number of HRQoL questionnaires exist for use with children and/or proxies, and both guidelines and reviews have been published on paediatric HRQoL. However, none address the challenges of measurement for children under five, for whom proxy measures should be used. In reality, there is significant heterogeneity in the cut-off age for self-report questionnaires. Recommendations are that proxies should be used for observable concepts, but not for concepts that require interpretation. Some research has been undertaken on dimensions/concepts in paediatric HRQoL questionnaires. However, no HRQoL models have been developed specifically for children, and heterogeneity in questionnaire dimensions underlines that there is no clear grasp of what HRQoL means in paediatric populations. There is a need to carry out research in order to develop theoretical models of HRQoL that are specific to children at different developmental stages, in order to evaluate and support new and existing measures for paediatric HRQoL and their use in clinical practice as well as clinical trials.

Development of an intervention to reduce antibiotic use for childhood coughs in UK primary care using critical synthesis of multi-method research

Background

Overuse of antibiotics contributes to the global threat of antimicrobial resistance. Antibiotic stewardship interventions address this threat by reducing the use of antibiotics in occasions or doses unlikely to be effective. We aimed to develop an evidence-based, theory-informed, intervention to reduce antibiotic prescriptions in primary care for childhood respiratory tract infections (RTI). This paper describes our methods for doing so.

Methods

Green and Krueter’s Precede/Proceed logic model was used as a framework to integrate findings from a programme of research including 5 systematic reviews, 3 qualitative studies, and 1 cohort study. The model was populated using a strength of evidence approach, and developed with input from stakeholders including clinicians and parents.

Results

The synthesis produced a series of evidence-based statements summarizing the quantitative and qualitative evidence for intervention elements most likely to result in changes in clinician behaviour. Current evidence suggests that interventions which reduce clinical uncertainty, reduce clinician/parent miscommunication, elicit parent concerns, make clear delayed or no-antibiotic recommendations, and provide clinicians with alternate treatment actions have the best chance of success. We designed a web-based within-consultation intervention to reduce clinician uncertainty and pressure to prescribe, designed to be used when children with RTI present to a prescribing clinician in primary care.

Conclusions

We provide a worked example of methods for the development of future complex interventions in primary care, where multiple factors act on multiple actors within a complex system. Our synthesis provided intervention guidance, recommendations for practice, and highlighted evidence gaps, but questions remain about how best to implement these recommendations. The funding structure which enabled a single team of researchers to work on a multi-method programme of related studies (NIHR Programme Grant scheme) was key in our success.

Trial registration

The feasibility study accompanying this intervention was prospectively registered with the ISRCTN registry (ISRCTN23547970), on 27 June 2014.

Electronic supplementary material

The online version of this article (10.1186/s12874-017-0455-9) contains supplementary material, which is available to authorized users.

Patient-provider communication in nephrology care for adolescents and young adults

OBJECTIVE

To compare the relative quantity of talk between providers, caregivers, and adolescents and young adults (AYAs) with chronic kidney disease (CKD) and how communication differs by age.

METHODS

During nephrology clinic visits, conversations between AYAs with CKD (N=99, ages 11-20, median=15), their caregivers, and providers (N=19) were audiotaped and coded using the Roter Interaction Analysis System. Linear mixed models tested AYA age differences in talk frequency by AYAs, caregivers, and providers. Post-hoc analyses tested differences in talk using AYA age groups.

RESULTS

During clinic visits, providers spoke the most (63.7%), and caregivers spoke more (22.6%) than AYAs (13.7%). Overall talk differed by AYA age in AYAs (p<0.001) and caregivers (p<0.05), but not providers. Higher AYA age was associated with more AYA talk (biomedical information-giving, partnering, rapport-oriented) and less caregiver biomedical information-giving (ps<0.001-0.05). In post-hoc analyses, young adults talked more than adolescents; caregiver talk decreased in the middle-adolescent group.

CONCLUSIONS

Increases in AYA talk occur primarily in young adulthood, whereas caregiver talk decreases in middle adolescence. This may indicate an appropriate developmental shift but raises concerns about conversational gaps during middle-adolescence.

PRACTICE IMPLICATIONS

During transition-oriented treatment planning, providers should engage both AYAs and caregivers to avoid potential gaps in communication.

Speech Perceptions and Health-Related Quality of Life Among Children With Cleft Lip and Palate

BACKGROUND

The association between perception of speech and health-related quality of life (HRQOL) among patients with cleft palate is not well understood. The purpose of this study was to determine: the agreement between patient and parent perception of speech, the correlation between patient/parent speech perception and objective analysis by a speech-language pathologist (SLP), and the relationship between objective speech analysis and HRQOL among children with cleft lip with or without palate (CLCP).

METHODS

The authors surveyed 108 CLCP patients who received treatment at a large tertiary medical center from 2013 to 2014. Patients and parents were queried regarding their difficulty with speech, and an SLP performed perceptual speech analysis with each patient. Patient-reported survey instruments were used to assess anxiety, depression, anger, peer relationships, stigma, and overall psychosocial health. The authors assessed the agreement between patients and SLP analysis as well as association between speech and HRQOL.

RESULTS

Patient and parent-reported speech quality demonstrated moderate agreement regarding the quality of the child's speech (r = 0.46-0.64). Parent and patient speech perception was not well associated with SLP analysis (V = 0.06-0.30). Patient speech perception was correlated with depression (P = 0.03), while SLP analysis was correlated with anger (P = 0.03, P = 0.004), depression (P = 0.007), and difficulty with peer relationships (P = 0.02).

CONCLUSIONS

Patients and parents have different perceptions of the quality of the child's speech, and their ratings differ from SLP perceptual speech analysis. Both patient speech perception and SLP analysis are correlated with important aspects of quality of life, and should be considered when evaluating children with CLCP.

Health-Related Quality of Life and the Desire for Revision Surgery Among Children With Cleft Lip and Palate

PURPOSE

Children with cleft lip with or without palate (CLCP) require multiple reconstructive procedures, however, little is known about their desire for surgical revision. The purpose of this study was to examine the relationship between health-related quality of life (HRQOL) and the desire for revision.

METHODS

The authors surveyed children with CLCP (n = 71) and their caregivers regarding general and cleft-specific HRQOL and the desire for revision surgery. The authors used logistic regression models to evaluate the relationship between HRQOL and the desire for revision stratified by age, and determined the level of agreement between caregivers and children.

RESULTS

In this cohort, 54.9% of children desired revision, primarily of the nose (n = 23), lip (n = 20), and dentoalveolar structures (n = 19). Children 11 years or older were more likely to desire revision than younger children (OR 3.39, 95% CI [1.19, 9.67], P <0.05). Children who reported poorer HRQOL with respect to appearance (OR 2.31, 95% CI [1.25-4.29], P = 0.008), social development (OR 0.91, 95% CI [0.84-0.99], P = 0.02), and communication (OR 0.94, 95% CI [0.89-0.99], P = 0.02) were significantly more likely to desire revision than children who reported more positive HRQOL. Caregivers' and children's desires for revision were only modestly correlated (r = 0.41).

CONCLUSIONS

Children with CLCP who report poorer HRQOL are more likely to desire revision than children with higher HRQOL; these differences are further magnified among older children. Given the modest correlation between patient and caregiver goals for revision, it is important to evaluate both perspectives when considering revision surgery.

Effects of pre-consultation lists on the communicative behavior of children with cancer and their caregivers

Abstract This cross-sectional study present effects of pre-consultation lists on caregivers' and children's communicative behavior. Thirty-two dyads caregiver-child took part in this research, divided in three groups concerning the study design: Baseline 1, Intervention phase, and Baseline 2. Children and caregivers were individually interviewed before consultations on pediatric cancer treatment, in order to list doubts, expectations, and estimated issues to the medical visit. These themes were written down on a sheet of paper, attached to the child´s medical record cover, and would then be used as a memo in the following consultation. Results show that pre-consultation lists produced no effects on children's behavior, however the procedure was associated to specific doubts discussed by caregivers regarding dietary recommendations, coping with side effects, child development, biological aspects of cancer, and school activities. This study presents a low cost procedure that may contribute to tailor communication in pediatric settings.

‘What Brings Him Here Today?’: Medical Problem Presentation Involving Children with Autism Spectrum Disorders and Typically Developing Children

Conversation and discourse analyses were used to examine medical problem presentation in pediatric care.Healthcare visits involving children with ASD and typically developing children were analyzed. We examined how children’s communicative and epistemic capabilities, and their opportunities to be socialized into a competent patient role are interactionally achieved. We found that medical problem presentation is designed to contain a ‘pre-visit’ account of the interactional and epistemic work that children and caregivers carry out at home to identify the child’s health problems; and that the intersubjective accessibility of children’s experiences that becomes disrupted by ASD presents a dilemma to all participants in the visit. The article examines interactional roots of unmet healthcare needs and foregone medical care of people with ASD.

Decision Making in Paediatric Care: an overview with reference to nursing care

The purpose of this overview of published articles on decision making in paediatric care was to identify important aspects of its possible use in clinical practice and to obtain a base for future research. A literature review was undertaken utilizing snowball sampling to identify articles because of the diversity present within the area of decision making in paediatric care. The databases PubMed and CINAHL were used. The search was limited to articles published in English during the period 1994-2004. The analysis entailed a series of comparisons across articles, focusing on major areas of enquiry and patterns of results. Various levels of decision making are described because these seem to form a basis for how decisions are made. Concepts found to be of importance for decision making are described under the following headings: competence, the child’s best interests, knowledge, values and attitudes, roles and partnership, power, and economy. Further research is suggested.

Multisystemic Therapy Improves the Patient-Provider Relationship in Families of Adolescents with Poorly Controlled Insulin Dependent Diabetes

The purpose of this study was to determine if multisystemic therapy (MST), an intensive, home and community-based family treatment, significantly improved patient-provider relationships in families where youth had chronic poor glycemic control. One hundred forty-six adolescents with type 1 or 2 diabetes in chronic poor glycemic control (HbA1c ≥8 %) and their primary caregivers were randomly assigned to MST or a telephone support condition. Caregiver perceptions of their relationship with the diabetes multidisciplinary medical team were assessed at baseline and treatment termination with the Measure of Process of Care-20. At treatment termination, MST families reported significant improvement on the Coordinated and Comprehensive Care scale and marginally significant improvement on the Respectful and Supportive Care scale. Improvements on the Enabling and Partnership and Providing Specific Information scales were not significant. Results suggest MST improves the ability of the families and the diabetes treatment providers to work together.

Effective Patient-Provider Communication in Pediatric Obesity

Effective patient-provider communication is not a primary focus of medical school curricula. Motivational interviewing (MI) is a patient-centered, directive communication framework appropriate for in health care. Research on MI's causal mechanisms has established patient change talk as a mediator of behavior change. Current MI research focuses on identifying which provider communication skills are responsible for evoking change talk. MI recommends informing, asking, and listening. Research provides evidence that asking for and reflecting patient change talk are effective communication strategies, but cautions providers to inform judiciously. Supporting a patient's decision making autonomy is an important strategy to promote health behaviors.

Health professionals' perspectives on children's and young people's participation in health care: a qualitative multihospital study

AIMS AND OBJECTIVES

To investigate healthcare professionals' perspectives on child participation in paediatric hospital care and their opinions on improving participation practices.

BACKGROUND

Some scholars argue that the decision-making capacities of children largely depend on the attitudes of healthcare professionals rather than on the children's own competences. Healthcare professionals' perspectives on children's participation in hospital care remain largely unexplored.

DESIGN

Qualitative descriptive design.

METHODS

Healthcare professionals (n = 32) from 10 paediatric wards in the Netherlands participated in semi-structured interviews. Shier's Pathways to Participation model (2001) was used to guide the interviews.

RESULTS

Participation is not a term that is frequently used by professionals; however, they feel familiar with the ideas underlying the term, and it is perceived as being at the core of their work. Professionals believe that high levels of participation are possible in basic care for children. Participation in medical decision-making is considered to be more complex and subject to a number of reservations and restrictions. The participants expressed a strong need to enhance child participation in service evaluation and to increase the respect for and understanding of the rights of children to participate outside of the paediatric unit, including in the surgery and emergency departments.

CONCLUSION

Children do not currently participate in the assessment of hospital services. Creative methods that support the role of children in evaluating and improving the quality of paediatric hospital care and services should be developed. Hospital-wide policies could help to promote understanding of child participation among all professionals caring for children in hospitals.

RELEVANCE TO CLINICAL PRACTICE

Based on international agreements that the Netherlands has ratified, professionals have the duty to facilitate child participation in hospital care. Concrete opportunities and ideas on how to accomplish this goal in practice are provided, and areas for improvement are identified.

Sharing decisions during diagnostic consultations; an observational study in pediatric oncology

OBJECTIVE

Children and parents need to make important decisions in the period of being informed about the diagnosis of childhood cancer. Although parents' and children's involvement is legally required, it is unclear whether oncologists involve them. This study explored which decisions families face, how oncologists involve them in shared decision-making (SDM) and which factors are associated with this process.

METHODS

Forty-three families with children, starting treatment for childhood cancer, were recruited from three Dutch academic pediatric oncology clinics. Diagnostic consultations were audio-taped and coded with the OPTION.

RESULTS

On average, 3.5 decisions were discussed per consultation. Most frequently discussed decisions concerned registration in a patient database (42%) and how to deal with hair loss (33%). Oncologists' assistance in SDM focused on giving information and ensuring the parents' and the child's understanding. The hospital in which children were treated (F(2,2)=5.39, p=.01) and discussing trial participation (F(1,1)=8.11, p=.01) were associated with oncologists' assistance.

CONCLUSION

Decision-making during diagnostic consultations appears to focus on non-treatment related decisions. Oncologists' assistance mostly concerned sharing information, instead of SDM.

PRACTICE IMPLICATIONS

Additional research is needed to provide insight in how to increase oncologists' assistance, while taking into account children's and parents' preferences concerning SDM.

'[I would like] a place to be alone, other than the toilet'--Children's perspectives on paediatric hospital care in the Netherlands

BACKGROUND

Although it is widely recognized that children are willing, capable and legally entitled to be active participants in their health care, parents are generally invited to evaluate paediatric hospital care and services rather than children themselves. This is problematic because parents cannot serve as the only spokespersons for the perspectives and experiences of children.

OBJECTIVE

To investigate children's experiences with and perspectives on the quality of hospital care and services in the Netherlands, and how they think care and services could be improved.

DESIGN

A qualitative study incorporating different participatory data collection methods, including photovoice and children writing a letter to the chief executive of the hospital.

SETTING

Paediatric departments of eight hospitals in the Netherlands (two teaching and six regional).

PARTICIPANTS

Children and adolescents (n = 63) with either acute or chronic disorders, aged between 6 and 18 years.

RESULTS

The research results provide insights into children's health and social well-being in hospitals. Important aspects of health, like being able to sleep well and nutrition that fits children's preferences, are structurally being neglected.

CONCLUSION

The participatory approach brought children's ideas 'alive' and generated concrete areas for improvement that stimulated hospitals to take action. This demonstrates that participatory methods are not merely tools to gather children's views but can serve as vehicles for creating health-care services that more closely meet children's own needs and wishes.

Do Patient- and Parent-reported Outcomes Measures for Children With Congenital Hand Differences Capture WHO-ICF Domains?

BACKGROUND

Patient- and parent-reported outcome measures (PROMs) are increasingly used to evaluate the effectiveness of surgery for congenital hand differences (CHDs). Knowledge of an existing outcome measure's ability to assess self-reported health, including psychosocial aspects, can inform the future development and application of PROMs for CHD. However, the extent to which measures used among children with CHD align with common, accepted metrics of self-reported disability remains unexplored.

QUESTIONS/PURPOSES

We reviewed studies that used PROMs to evaluate surgery for CHD to determine (1) the number of World Health Organization-International Classification of Functioning, Disability and Health (WHO-ICF) domains covered by existing PROMs; (2) the proportion of studies that used PROMs specifically validated among children with CHD; and (3) the proportion of PROMs that targets patients and/or parents.

METHODS

We performed a comprehensive review of the literature through a bibliographic search of MEDLINE®, PubMed, and EMBASE from January 1966 to December 2014 to identify articles related to patient outcomes and surgery for CHD. We evaluated the 42 studies that used PROMs to identify the number and type of WHO-ICF domains captured by existing PROMs for CHD and the proportion of studies that use PROMs validated for use among children with CHD. The most common instruments used to measure patient- and parent-reported outcomes after reconstruction for CHD included the Prosthetic Upper Extremity Functional Index (PUFI), Disabilities of the Arm, Shoulder, and Hand questionnaire, Childhood Experience Questionnaire, and Pediatric Quality of Life Inventory.

RESULTS

Current PROMs that have been used for CHD covered a mean of 1.3 WHO-ICF domains (SD ± 1.3). Only the Child Behavior Checklist and the Piers-Harris Children's Self-Concept Scale captured all ICF domains (body functions and structures, activity, participation, and environmental factors). The PUFI, the only PROM validated specifically for children with congenital longitudinal and transverse deficiency, was used in only four of 42 studies. Only 13 of the 42 studies assessed patient-reported outcomes, whereas five assessed both patient- and parent-reported outcomes.

CONCLUSIONS

The PROMs used to assess patients after CHD surgery do not evaluate all WHO-ICF domains (ie, body structure, body function, environmental factors, and activity and participation) and generally are not validated for children with CHD. Given the psychological and sociological aspects of CHD illness, a PROM that encompasses all components of the biopsychosocial model of illness and validated in children with CHD is desirable.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Correlates of type and quantity of child communication during pediatric subspecialty encounters

OBJECTIVES

Understanding the factors associated with child communication during subspecialty encounters may inform interventions promoting shared decision-making in chronic disease management. Objectives were to (1) describe the quantity and quality of child communication during outpatient subspecialty encounters and (2) determine if and how the quantity and quality of child communication vary by demographic and visit characteristics.

METHODS

We videotaped subspecialty clinic encounters involving 20 health care providers and 155 children with one of the following conditions: acute lymphoblastic leukemia (consolidation/maintenance), persistent asthma, cystic fibrosis, type 1 diabetes, and obesity. The Roter interaction analysis system was used to code child utterances into one of 10 discrete categories.

RESULTS

Children exhibited a mean of 15% of all utterances made during clinical encounters. Children spoke more during obesity encounters.

CONCLUSIONS

Similar to the findings of studies in primary care settings, children spoke infrequently during the subspecialty visits, and the most common utterances tended to be replies to questions from adults.

PRACTICE IMPLICATIONS

In this study, there was relatively higher engagement of children during obesity clinic encounters in the area of lifestyle choices. Strategies used to engage children in conversation in obesity clinics may be useful for engaging children in other subspecialty clinics.

Does Media Use Result in More Active Communicators? Differences Between Native Dutch and Turkish-Dutch Patients in Information-Seeking Behavior and Participation During Consultations With General Practitioners

This study investigates differences between native Dutch and Turkish-Dutch patients with respect to media usage before and patient participation during medical consultations with general practitioners. In addition, the authors assessed the relation between patient participation and communication outcomes. The patients were recruited in the waiting rooms of general practitioners, and 191 patients (117 native Dutch, 74 Turkish-Dutch) completed pre- and postconsultation questionnaires. Of this sample, 120 patients (62.8%; 82 native Dutch, 38 Turkish-Dutch) agreed to have their consultations recorded to measure patient participation. Compared with Turkish-Dutch patients of similar educational levels, results showed that native Dutch patients used different media to search for information, participated to a greater extent during their consultations and were more responsive to their general practitioner. With respect to the Turkish-Dutch patients, media usage was related to increased patient participation, which was correlated with having fewer unfulfilled information needs; however, these relations were not found in the native Dutch patient sample. In conclusion, interventions that enhance participation among ethnic minority patients will better fulfill informational needs when such interventions stimulate information-seeking behavior in that group before a medical consultation.

Evolution of Pediatric Chronic Disease Treatment Decisions: A Qualitative, Longitudinal View of Parents' Decision-Making Process

BACKGROUND

In the context of pediatric chronic conditions, patients and families are called upon repeatedly to make treatment decisions. However, little is known about how their decision making evolves over time. The objective was to understand parents' processes for treatment decision making in pediatric chronic conditions.

METHODS

We conducted a qualitative, prospective longitudinal study using recorded clinic visits and individual interviews. After consent was obtained from health care providers, parents, and patients, clinic visits during which treatment decisions were expected to be discussed were video-recorded. Parents then participated in sequential telephone interviews about their decision-making experience. Data were coded by 2 people and analyzed using framework analysis with sequential, time-ordered matrices.

RESULTS

21 families, including 29 parents, participated in video-recording and interviews. We found 3 dominant patterns of decision evolution. Each consisted of a series of decision events, including conversations, disease flares, and researching of treatment options. Within all 3 patterns there were both constant and evolving elements of decision making, such as role perceptions and treatment expectations, respectively. After parents made a treatment decision, they immediately turned to the next decision related to the chronic condition, creating an iterative cycle.

CONCLUSION

In this study, decision making was an iterative process occurring in 3 distinct patterns. Understanding these patterns and the varying elements of parents' decision processes is an essential step toward developing interventions that are appropriate to the setting and that capitalize on the skills families may develop as they gain experience with a chronic condition. Future research should also consider the role of children and adolescents in this decision process.

A proposal for a behavioral pre-consultation: Analysis of the use of a protocol during consultations

This study aimed to analyze how physicians, caregivers, and children use protocols regarding estimated issues to medical visits, procedure named pre-consultation lists, along treatment for childhood cancer. Three pediatricians and 24 dyads child-caregiver took part; each pair was interviewed before medical visits in order to report doubts, needs and issues estimated to the consultation. This list was attached to child's medical record as a memo of themes to discuss in the next medical visit. Results show that two physicians included effectively this file in their consultations and discussed a great amount of issues listed by caregivers and patients. Children did not refer to the listed issues, but parents, in smaller amounts, discussed the themes in the protocol. This procedure contributed to insert the child in consultations and it may facilitate the focus on specific themes, however the physician's main role in managing communication during pediatric medical visits is highlighted.

Provider-caregiver-child discussions about risks associated with asthma control medications: content and prevalence

OBJECTIVES

The objectives of this study were to: (1) describe the extent to which general pediatric providers discuss risks associated with asthma control medications with families, and (2) examine factors that are associated with risk discussions.

STUDY DESIGN

This study was a cross-sectional secondary analysis of audio taped medical visits involving 35 pediatric providers and 248 children with asthma with their caregivers. Transcripts of the visits were coded for discussions about asthma medication risks. Generalized estimating equations were used to analyze the data.

RESULTS

Providers discussed asthma control medication risks during 23% of visits. Risks were more likely to be discussed when the visit was longer and when the provider prescribed a new asthma control medication. When providers discussed asthma control medication risks, they were most likely to ask the family general questions and make general statements. Across all of the visits, caregivers asked a total of 16 questions and made a total of 20 statements about risks associated with asthma medications; children asked a total of 3 questions and made two statements about risks associated with asthma control medications.

CONCLUSION

Providers discussed risks associated with asthma control medications in less than one-quarter of medical visits. Providers should involve families in discussions about risks associated with medications during every visit to assess potential barriers to medication adherence.

Real life clinic visits do not match the ideals of shared decision making

OBJECTIVE

To use observation to understand how decisions about higher-risk treatments, such as biologics, are made in pediatric chronic conditions.

METHODS

Gastroenterology and rheumatology providers who prescribe biologics were recruited. Families were recruited when they had an outpatient appointment in which treatment with biologics was likely to be discussed. Consent/assent was obtained to video the visit. Audio of the visits in which a discussion of biologics took place were transcribed and analyzed. Our coding structure was based on prior research, shared decision making (SDM) concepts, and the initial recorded visits. Coded data were analyzed using content analysis and comparison with an existing model of SDM.

RESULTS

We recorded 21 visits that included discussions of biologics. In most visits, providers initiated the decision-making discussion. Detailed information was typically given about the provider's preferred option with less information about other options. There was minimal elicitation of preferences, treatment goals, or prior knowledge. Few parents or patients spontaneously stated their preferences or concerns. An implicit or explicit treatment recommendation was given in nearly all visits, although rarely requested. In approximately one-third of the visits, the treatment decision was never made explicit, yet steps were taken to implement the provider's preferred treatment.

CONCLUSIONS

We observed limited use of SDM, despite previous research indicating that parents wish to collaborate in decision making. To better achieve SDM in chronic conditions, providers and families need to strive for bidirectional sharing of information and an explicit family role in decision making.

"They just say everything's a virus"--parent's judgment of the credibility of clinician communication in primary care consultations for respiratory tract infections in children: a qualitative study

OBJECTIVE

To investigate parents' experiences and views of clinician communication during primary care consultations for respiratory tract infections (RTIs) in children under 12.

METHODS

Semi-structured interviews with 30 parents who had recently consulted for RTI in their child. Purposive sampling was used to interview parents from a range of socio-economic areas.

RESULTS

Parents critically assess the credibility of primary care clinician diagnosis and treatment recommendations based on their perception of the medical evaluation and how well their concerns and expectations have been addressed. A "viral" diagnosis could be perceived as trivializing, particularly when contradicting the parent's perception of severity. Parents expected advice on symptomatic treatment and felt frustrated by 'no treatment' recommendations. Parents commonly reported safety netting advice which was too vague to be useful.

CONCLUSION

Parents' perception of the credibility of the diagnosis and treatment recommendations is influenced both by their expectations and the effectiveness of clinician communication. Opportunities are being missed to inform parents about symptomatic care and when to consult for children with RTIs.

PRACTICE IMPLICATIONS

Clinicians should tailor diagnostic explanations to parental expectations and concerns and address the symptoms of significance to parents. Clinicians should provide advice about symptom relief and more precise safety netting advice.

How communication affects prescription decisions in consultations for acute illness in children: a systematic review and meta-ethnography

Background

Communication within primary care consultations for children with acute illness can be problematic for parents and clinicians, with potential misunderstandings contributing to over–prescription of antibiotics. This review aimed to synthesise the evidence in relation to communication and decision making in consultations for children with common acute illness.

Methods

A systematic search of MEDLINE, EMBASE, CINAHL, PsycINFO, SSCI, SIGLE, Dissertation Express and NHS economic evaluation databases was conducted. Studies of primary care settings in high income countries which made direct observations of consultations and reported qualitative data were included. Included studies were appraised using the process recommended by the Cochrane Qualitative Methods Group. Credibility was assessed as high for most studies but transferability was usually assessed low or unclear. Data were synthesised using a meta–ethnographic approach.

Results

Thirty–five papers and 2 theses reporting on 13 studies were included, 7 of these focussed on children with respiratory tract infections (RTI) and the remaining 6 included children with any presenting illness. Parent communication focussed on their concerns and information needs, whereas clinician communication focussed on diagnosis and treatment decisions. During information exchanges, parents often sought to justify the need for the consultation, while clinicians frequently used problem minimising language, resulting in parents and clinicians sometimes talking at cross–purposes. In the context of RTIs, a range of parent communication behaviours were interpreted by clinicians as indicating an expectation for antibiotics; however, most were ambiguous and could also be interpreted as raising concerns or requests for further information. The perceived expectation for antibiotics often changed clinician decision making into clinician–parent negotiation.

Conclusions

Misunderstandings occurred due to parents and clinicians talking at cross purposes about the ‘seriousness’ of the illness and because parents’ expressions of concern or requests for additional information were sometimes perceived as a challenge to the clinicians’ diagnosis or treatment decision. This modifiable problem may be an important contribution to the unnecessary and unwanted prescribing of antibiotics. Primary care clinicians should be offered training to understand parent communication primarily as expressions of concern or attempts at understanding and always to check rather than infer parental expectations.

How often do providers discuss asthma action plans with children? Analysis of transcripts of medical visits

OBJECTIVE

To examine how often providers discussed asthma action plans with children and their caregivers and child, clinical, and provider characteristics that were associated with those discussions.

METHOD

This was a cross-sectional analysis of audio-recorded visits between 35 general pediatric providers and 260 children (8-16 years old) with asthma and their caregivers. The visits were transcribed into text. The transcripts were coded for discussions about written asthma action plans.

RESULTS

Providers discussed written asthma action plans with 21.0% of children and caregivers. Providers were significantly more likely to discuss asthma action plans when the child was enrolled in Medicaid, the visit was asthma related, the visit was longer, the provider was not White, or more provider education.

CONCLUSION

In our sample, providers rarely discussed action plans with children and their caregivers. Providers should discuss asthma action plans with every child with persistent asthma and their caregivers and revise them regularly.

Communication in the initial paediatric consultation

The first time a paediatrician meets with a patient, either with or without parents or caretakers, there are generally two aims with this consultation. Aside from exchanging relevant information for diagnosis, a relationship develops. This relationship is an important factor in the encounter: it can facilitate or impede collaboration between the partners in the consultation. The paediatrician can influence this relationship so that it becomes beneficial in the diagnostic process and in creating a collaborative atmosphere in the consultation, which in turn will prove useful for adherence. This paper addresses this second aim: how can we use the relationship between the patients (with or without parents) and their doctors to enhance the quality and effectiveness of the encounter. Below we will first address why investing in a relationship is beneficial. Next we will describe how this can be done. The review will continue with a discussion of three important pitfalls and how to avoid them, and a small epilogue will provide a brief summary.

Comunicação em pediatria: revisão sistemática de literatura

A qualidade da comunicação em Pediatria influencia diretamente o sucesso do tratamento, ao promover níveis satisfatórios de adesão, retenção de informações e acolhimento a demandas biopsicossociais. Constituiu objetivo deste trabalho realizar uma revisão sistemática da literatura referente à comunicação em pediatria publicada entre 2000 e 2010. Foram selecionados trabalhos incluídos nas bases de dados PubMed/MedLine, Bireme/BVS e ScienceDirect, Portal de Periódicos da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior e SciELO. Os 61 trabalhos selecionados indicam prevalência de delineamentos descritivos e técnicas de análise qualitativas e quantitativas, em detrimento de estudos experimentais e uso de técnicas mistas para análise de dados. A literatura indica a importância da inclusão do paciente pediátrico no processo de comunicação e do acolhimento a demandas psicossociais, destacando que programas para melhoria da comunicação têm obtido bons resultados. Destaca-se a importância de estudos sistemáticos que possibilitem compreender os fatores envolvidos na comunicação em pediatria e a inserção de programas psicossociais eficientes.

Shared Medical Appointments marginally enhance interaction between patients: an observational study on children and adolescents with type 1 diabetes

OBJECTIVE

To examine informational and emotional patient-provider and patient-patient communication sequences (i.e. cues and subsequent responses) during Shared Medical Appointments (SMAs) for children and adolescents with type 1 Diabetes Mellitus (T1DM) and their parents.

METHODS

57 children/adolescents with T1DM and 36 healthcare providers participated in ten SMAs in seven Dutch hospitals. Parents were present in six SMAs. Video-recordings were made. Communication sequences, including informational and emotional cues and responses were rated using an adaptation of the Medical Interview Aural Rating Scale.

RESULTS

143 patient-initiated cues were identified, followed by 140 provider responses and 30 patient responses. Patients gave more informational than emotional cues. Informational cues were mostly medical-related. Subsequent responses provided by providers and patients contained mostly appropriate information. We identified 17 patient and four parent cues with multiple responses.

CONCLUSIONS

Almost all cues were identified by healthcare providers and responded to in an appropriate manner. Cues not followed by a provider's response were picked up by other patients. Providers acted as mediator between a patient cue and another patient's response, thereby stimulating the interaction during SMAs.

PRACTICE IMPLICATIONS

Professionals could more explicitly invite all participants to interact with each other, and enable them to have their share in the communication process.

Knowledge and attitude of school children in Amman/Jordan toward the appropriate use of medicines: A cross-sectional study

OBJECTIVES

The aim of this study is to examine the knowledge, practice, and attitude toward medications of different primary school children at age group (7-9) years.

METHODS

This cross sectional study adopted the form of structured interviewing technique using a validated and pre-piloted questionnaire. The questionnaire consisted of a mixture of multiple choice and open-ended questions, 15 USP pictograms and six dosage form demos. A randomized stratified target sample of 200 students (n = 100 of each gender), of the first, second and third grades from the four Amman Education Directorates was recruited. School children were interviewed regarding their knowledge, attitude and the way they think medicines should be used.

RESULTS

The mean score value achieved by children in all the knowledge questions was 23.26 ± 0.25 out of 32, which was considered as satisfactory knowledge by the research team. The most significant factors affecting children's knowledge (including: multiple choice questions, pictograms and dosage forms) were: age, school/area of residency, and the presence of a first-degree relative working in a medical job. The majority of participants (79%) stated that the taste of the medication was the main factor to prevent them from taking their medication.

CONCLUSION

In general, school children in our sample have satisfactory knowledge and a generally positive attitude toward medicines. However, school curricula in Jordan should include more education regarding the effective and safe use of medicines.

Influence of race and socioeconomic status on engagement in pediatric primary care

OBJECTIVE

To understand the association of race/ethnicity with engagement in pediatric primary care and examine how any racial/ethnic disparities are influenced by socioeconomic status.

METHODS

Visit videos and parent surveys were obtained for 405 children who visited for respiratory infections. Family and physician engagement in key visit tasks (relationship building, information exchange, and decision making) were coded. Two parallel regression models adjusting for covariates and clustering by physician were constructed: (1) race/ethnicity only and (2) race/ethnicity with SES (education and income).

RESULTS

With and without adjustment for SES, physicians seeing Asian families spoke 24% fewer relationship building utterances, compared to physicians seeing White, non-Latino families (p<0.05). Latino families gathered 24% less information than White, non-Latino families (p<0.05), but accounting for SES mitigates this association. Similarly, African American families were significantly less likely to be actively engaged in decision making (OR=0.32; p<0.05), compared to White, non-Latino families, but adjusting for SES mitigated this association.

CONCLUSION

While engagement during pediatric visits differed by the family's race/ethnicity, many of these differences were eliminated by accounting for socioeconomic status.

PRACTICE IMPLICATIONS

Effective targeting and evaluation of interventions to reduce health disparities through improving engagement must extend beyond race/ethnicity to consider socioeconomic status more broadly.

Physician-child interaction: when children answer physicians' questions in routine medical encounters

OBJECTIVE

The objective of the study is to examine predictors of children answering questions during primary care pediatric visits.

METHODS

Relying on a sample of 322 video-taped community practice encounters, this study identifies predictors of when children answer physicians' questions. Multi-level multivariate regressions were used to model the relationships among communication and socio-demographic variables and whether or not children answered questions pediatricians asked them.

RESULTS

Whereas race and education predict whether physicians select children to answer questions, these factors are not associated with whether children answer physicians' questions. Instead, a child's performance is associated with communication practices specific to physician-child interaction such as the grammatical type of question and doctor gaze.

CONCLUSION

Children are less responsive to physicians' questions than their parents but their failure to answer is predictable and thus can be improved. By increasing their participation in the visit, physicians may (a) secure more information about children's health and (b) socialize children to be more pro-active patients.

PRACTICE IMPLICATIONS

Physicians can improve the likelihood that children will answer their questions by (a) asking them social questions early in the visit, (b) phrasing their questions as yes-no questions, and (c) and directing their gaze at the children during each question.

Children's participation in decision-making: balancing protection with shared decision-making using a situational perspective

Children's participation in decision-making in the health care setting is complex because parents and health professionals tend to take a protective stance towards children to act in their best interest. Children prefer to be protected in some situations and to share decision-making in others. Adults in the health care setting need to consider children as individuals, rather than as a homogenous group, and take into account that a child's competence and preferences will depend on the circumstances in every situation. This article argues for a situational perspective of children's participation to act in the child's best interest and to balance protection with shared decision-making, according to children's rights and desires.

Unraveling triadic communication in hospital consultations with adolescents with chronic conditions: the added value of mixed methods research

OBJECTIVE

To integrate findings of a mixed methods research (MMR) into adolescents' preferences and competencies for communication during consultations, in order to demonstrate the added value of MMR for health communication research.

METHODS

Sequential MMR with adolescents (12-19 years) with various chronic conditions in a university hospital. Methods comprised: (1) 31 face-to-face interviews; (2) Q-methodology; (3) 39 observations of outpatient consultations; (4) three focus groups with 27 healthcare providers; (5) web-based questionnaire in 960 adolescents.

RESULTS

Adolescents had different preferences regarding health communication, but all wished to be involved as partners. Yet, their actual participation during consultations was low. They often acted as bystanders rather than main characters because their participation was neither requested nor encouraged. Parents filled the gap, to healthcare providers' frustration. The questionnaire confirmed the discrepancy between self-efficacy and self-reported independent behavior during consultations.

CONCLUSION

Triadic communication was all but multi-party-talk and adolescents did not act and were not considered as main partners. MMR was of pivotal importance for our understanding.

PRACTICE IMPLICATIONS

As chronically ill adolescents need to prepare themselves for transition to adult care, healthcare providers should encourage them to take the lead in communication by initiating independent visits and changing the parents' roles.

Exciting but exhausting: experiences with participatory research with chronically ill adolescents

BACKGROUND

Adolescents with chronic conditions are major users of paediatric hospitals, but seldom participate in the evaluation of services or in research. Little is known about the usefulness of the participatory approach in adolescent health research.

OBJECTIVE

To evaluate the feasibility, benefits and limitations of a participatory research (PR) project involving chronically ill adolescents as co-researchers.

DESIGN SETTING AND PARTICIPANTS

Nine adolescents, aged 15-17 years, acted as co-researchers in a hospital-based PR project. They co-developed an interview protocol and during a disco party held for this purpose interviewed each other and 25 fellow patients (12-19 years). They provided advice on the draft report and participated in the dissemination of the results, but were not involved in the design of the project or analysis of results.

RESULTS

Involving adolescents in participatory health research was feasible and appreciated by researchers and youth alike, but had its drawbacks too. The peer-research attracted few participants, the interviews lacked depth and did not yield substantial new insights. Maintaining a high level of participation of the chronically ill co-researchers also proved difficult.

CONCLUSIONS

Adolescents with chronic conditions like to have a say in the design and evaluation of hospital services. But their participation as co-researchers demands ample resources from all parties involved without automatically improving research quality. PR does not seem the most effective and efficient way to make services more responsive. We therefore recommend further exploration of other creative and sustainable ways for involving youth in health-care service development and innovation.

Anti-Smoking Communication to Preadolescents with and without a Cancer Diagnosis: Parents and Healthcare Providers as Important Communicators

A cancer diagnosis does not prevent smoking among pediatric oncology patients, and anti-smoking communications among parents and health care providers have been proposed as influencing smoking outcomes in this group. Anti-smoking communications were compared among 93 preadolescents with cancer and 402 controls. After adjusting for demographics and covariates, preadolescents with cancer were less likely than control participants to report receipt of anti-smoking messages from physicians and parents, and recalled more messages >/= 4 months post-diagnosis as compared to 1-3 months. Should anti-tobacco communications prove to influence smoking outcomes, parents and physicians may be uniquely positioned to provide smoking prevention interventions to these patients.

Attitudes of physicians and parents towards discussing infertility risks and semen cryopreservation with male adolescents diagnosed with cancer

BACKGROUND

In paediatric oncology, the risk of infertility due to treatment constitutes an important problem. For sexually mature male adolescents, sperm cryopreservation is an option, but discussing the topic is complex because of the sensitive nature and the limited time frame. In this article, we determined attitudes and preferred roles of physicians and parents towards discussing sperm banking with male adolescents.

METHODS

Qualitative multi-centre study, using in-depth semi-structured interviews with 14 physicians and 15 parents of male adolescents undergoing cancer treatment.

RESULTS

Although physicians and parents agreed that infertility would have a major impact on the future quality of life, they sometimes disagreed on whether the topic should be discussed with adolescents. Physicians always wanted a separate discussion with adolescents because of the sensitive nature and the experience that parents sometimes misjudged the stage of maturity of their son. Parents, however, wanted control over whether physicians discussed the topic with their child and what was said. Physicians did not accept this control and, when necessary, were willing to bypass the parents and discuss the topic with the adolescent even when parents refused consent.

CONCLUSIONS

Physicians face the difficult task of balancing between their ideas of what is in the (future) interest of the adolescent and accommodating parental wishes. We argue that, because of the private character of sexuality and the potentially inadequate maturity assessment by parents, semen cryopreservation should be discussed separately with adolescent and parents. In addition, there should be an open communication with parents to address potential discomforts.