Correlates of perceived shared decision making with parents of children with special healthcare needs: Findings from the PART-CHILD study

OBJECTIVE

To assess the extent of perceived shared decision making (SDM) with parents of pediatric patients and to examine its association with characteristics of patients, professionals, and healthcare facilities.

METHODS

Parents of pediatric patients (n = 4383) were recruited in 15 social pediatric centers in Germany and provided information on perceived SDM (binary CollaboRATEpediatric score: optimal versus suboptimal extent of SDM), child age and sex, type of impairment, appointment, and healthcare professional present at the appointment. Organizational characteristics were assessed in a cross-sectional survey of staff at the study sites.

RESULTS

Overall, 58.4% of parents reported an optimal extent of SDM. The optimal extent of SDM was more likely reported by parents of girls (OR=1.27, p < 0.001) and children with physical (as opposed to cognitive and combined) impairments (OR=1.30, p = 0.006), and after appointments attended by allied health professionals (OR=1.28, p = 0.004). In addition, parents in facilities receiving financing in addition to compensation by statutory health insurance funds were less likely to report an optimal extent of perceived SDM.

CONCLUSION

While SDM with parents was mostly related to individual characteristics of children and professionals at appointments, organizational characteristics seemed less relevant in our study.

PRACTICE IMPLICATIONS

Staff should be made aware of lower SDM with parents of boys, older children, and those with cognitive impairments, and trained to improve the SDM in these groups.

Perceived shared decision making and satisfaction with care among children and adolescents with special healthcare needs and their parents: Cross-sectional evidence from the PART-CHILD Study

OBJECTIVES

To compare shared decision making (SDM) and satisfaction with care (SWC), an indicator of care quality, between children with special healthcare needs (CSHCN) and parents and to assess the association between SDM and SWC in both groups.

METHODS

We recruited CSHCN ≥ 7 years and parents from 15 outpatient facilities that completed a paper questionnaire assessing SDM (highest vs. lower levels of SDM) and SWC. Differences in SDM and SWC were assessed with McNemar and paired t-tests. We used adjusted linear mixed models to investigate cross-sectional associations between SDM and SWC.

RESULTS

Based on data from 275 CSHCN and 858 parents, 39% and 64% of CSHCN and parents reported the highest level of SDM (p < 0.0001). No difference in SWC was observed (p = 0.36). Perceived SDM was associated with SWC in both groups (both p < 0.0001).

CONCLUSION

Associations between SDM and SWC reinforce the role of SDM for care quality. Large proportions of CSHCN and parents reporting suboptimal levels of SDM highlight the need for effective programs to promote SDM in the target population.

PRACTICE IMPLICATIONS

Until effective programs become available, healthcare professionals can use existing opportunities to involve CSHCN and parents in consultations (e.g., provide sufficient opportunities to ask questions).

Development and validation of a self-regulation scale within the German version of the Early Development Instrument

BACKGROUND

Early childhood self-regulation (SR) is key for many health- and education-related outcomes across the life span. Kindergarten age is a crucial period for SR development, and within this developmental window, potential SR difficulties can still be compensated for (e.g., through interventions). However, efficient measurement of SR through brief, comprehensive, and easy-to-use instruments that identify SR difficulties are scarce. To address this need, we used items of an internationally applied kindergarten teacher questionnaire-the Early Development Instrument (EDI) - to develop and validate a specific SR measurement scale.

METHODS

The psychometric evaluation and validation of the selected SR-items was performed in data collected with the German version of the EDI (GEDI), in two independent data sets - (a) the development dataset, with 191 children, and b) the validation dataset, with 184 children. Both included three- to six-year-old children and contained retest and interrater reliability data. First, three independent raters-based on theory-selected items eligible to form a SR scale from the two SR-relevant GEDI domains "social competence" and "emotional maturity". Second, exploratory and confirmatory factor analysis using structural equation modeling examined the item structure across both data sets. This resulted in a defined SR scale, of which internal consistency, test-retest and interrater reliability, cross-validation, and concurrent validity using correlation and descriptive agreements (Bland-Altman (BA) plots) with an existing validated SR-measuring instrument (the Kindergarten Behavioral Scales) were assessed.

RESULTS

Confirmatory factor analysis across both data sets yielded the best fit indices with 13 of the GEDI 20 items initially deemed eligible for SR measurement, and a three-factor structure: a) behavioral response inhibition, b) cognitive inhibition, c) selective or focused attention (RMSEA: 0.019, CFI: 0.998). Psychometric evaluation of the resulting 13-item-GEDI-SR scale revealed good internal consistency (0.92), test-retest and interrater reliability (0.85 and 0.71, respectively), validity testing yielded stability across populations and good concurrent validity with the Kindergarten Behavioral Scales (Pearson correlation coefficient: mean 0.72, range 0.61 to 0.84).

CONCLUSIONS

The GEDI contains 13 items suitable to assess SR, either as part of regular EDI developmental monitoring or as a valid stand-alone scale. This short 13-item (G)EDI-SR scale may allow early detection of children with SR difficulties in the kindergarten setting in future and could be the basis for public health intervention planning. To attain this goal, future research should establish appropriate reference values using a representative standardization sample.

[Attitudes Toward Influenza Vaccination in Fall/Winter 2021: Results of the COSMO Study]

AIM OF THE STUDY

There is a lack of knowledge about attitudes to influenza vaccination in Germany in 2021/2022. Based on the COSMO survey ("COVID-19 Snapshot Monitoring"), the aim of this study was to shed some light on this topic.

METHODS

Wave 49 (August 10 and 11, 2021) of the COSMO survey (n=967; Germany-wide non-probabilistic quota sample; 18 to 74 years).

RESULTS

This year, about one-third of respondents (and health care workers) plan to get a flu shot, and among the at-risk group of people aged 60 and older (up to 74 years in our sample), more than half. Correlates (such as gender: women with a lower likelihood of a planned flu shot) were identified.

CONCLUSION

Physicians should inform women in particular about the advantages of influenza vaccination, especially during the pandemic, and communicate data on the proven protective effect of influenza vaccination as convincingly as possible (e. g., using existing brochures).

Attitudes toward the pandemic and COVID-19 vaccination intention among German university students and the general population: Results from two cross-sectional surveys

Background

The COVID-19 pandemic has had an impact on nearly all people. Vaccines provide an effective tool to combat the pandemic, however, vaccination hesitancy remains an issue. This study aims to investigate (a) students' attitudes toward the pandemic, (b) potential differences in attitudes between university students and the general population, and (c) to examine predictors of vaccination intention in both samples.

Methods

In this cross-sectional study data from two research projects were analyzed and compared. First, attitudes toward the COVID-19 pandemic in German university students were assessed within a cross-sectional anonymous online survey (March-April 2021, N = 5,639) and analyzed quantitatively and also qualitatively (free text field answers examined positive and negative aspects of the pandemic). Second, data from a cross-sectional survey within the COVID-19 Snapshot Monitoring project (COSMO; 29^th wave of data collection, December 2020, N = 1,387) in the German general population was analyzed. Both samples, were compared in sharedly used variables, regarding attitudes toward the pandemic and vaccination intention, and factors associated with vaccination (logistic regression analyses).

Results

In comparison to the general population, university students were significantly more likely to report being worried about/thinking about the coronavirus and to perceive the coronavirus as overrepresented in the media (all p < 0.001). University students reported a more supportive attitude toward vaccinations in general (students: M = 4.57, SD = 0.85; general population: M = 3.92, SD = 1.27) and a significantly higher vaccination intention (students: n = 4,438, 78.7%; general population: n = 635, 47.7%) than the general population (p < 0.001). Regression analyses revealed that in university students, vaccination intention was significantly predicted by not having children, a supporting attitude toward vaccinations in general, the belief that the coronavirus is overrepresented in the media, and less thinking about/worrying about the coronavirus (all p < 0.05). In the general population, vaccination intention was significantly associated with male gender, higher age, not having children, a supporting attitude toward vaccinations in general, and the belief that the coronavirus is overrepresented in the media (p < 0.05). The qualitative analysis among university students revealed that the most frequently stated positive aspect of the pandemic was to be more flexible due to digitalization (n = 1,301 statements, 22.2%) and the most frequently stated negative aspect was restriction in social life (n = 3,572 statements, 24.2%).

Conclusion

The results indicate differences in the attitudes toward the pandemic between university students and the general population. In addition, differences regarding factors associated with vaccination intention were found in both samples. These results could be important to be considered when designing and targeting vaccination campaigns aiming at informing different population or age groups.

Study registration

DRKS00022424.

Evaluation of a Complex Intervention to Strengthen Participation-Centred Care for Children with Special Healthcare Needs: Protocol of the Stepped Wedge Cluster Randomised PART-CHILD Trial

INTRODUCTION

Participation is an important dimension of healthy child development and is associated with higher self-rated health, educational attainment and civic engagement. Many children with special healthcare needs (SHCN) experience limited participation and are thus at risk for adverse health and developmental outcomes. Despite this, interventions that promote participation in healthcare are scarce. We therefore evaluate the effectiveness of a complex age- and condition-generic intervention that strengthens participation-centred care involving parents and their children with SHCN by, inter alia, assessing preferences, specifying participation goals and facilitating shared decision-making in care.

METHODS AND ANALYSIS

In this study protocol we describe the design and procedures for an unblinded, stepped wedge, cluster randomised trial conducted in 15 German interdisciplinary healthcare facilities providing services for children aged 0-18 years with SHCN. Sites are randomised to five periods in which they switch from control to intervention condition in blocks of three. The intervention includes: (1) team training focused on participation-centred care, (2) introduction of a new software facilitating participation-focused documentation and (3) implementation support promoting the transfer of training content into routine care. Study sites deliver routine care while in the control condition. As primary outcome, the degree of perceived shared decision-making with parents (CollaboRATE^pediatric parent scale), a potential antecedent of achieving participation goals in everyday life, is assessed on one randomly selected day per week during the entire study period, directly following care appointments. We aim to sample 70 parents per study site and period. Additionally, participation of children is assessed within a closed embedded cohort with three parent and patient surveys. Intervention effectiveness will be modelled with a marginal model for correlated binary outcomes using generalised estimation equations and complete cases. A comprehensive mixed-methods process evaluation complements the effectiveness analyses.

Attitude toward a mandatory COVID-19 vaccination policy and its determinants: Evidence from serial cross-sectional surveys conducted throughout the pandemic in Germany

BACKGROUND

Mandating vaccination against COVID-19 is often discussed as a means to counter low vaccine uptake. Beyond the potential legal, ethical, and psychological concerns, a successful implementation also needs to consider citizens' support for such a policy. Public attitudes toward vaccination mandates and their determinants might differ over time and, hence, should be monitored.

METHODS

Between April 2020 and April 2021, we investigated public support for mandatory vaccination policies in Germany and examined individual correlates, such as vaccination intentions, confidence in vaccine safety, and perceived collective responsibility, using a series of cross-sectional, quota-representative surveys (overall N = 27,509).

RESULTS

Support for a vaccination mandate declined before the approval of the first vaccine against COVID-19 in December 2020 and increased afterwards. However, at the end of April 2021, only half of respondents were in favor of mandatory regulations. In general, mandates were endorsed by those who considered the vaccines to be safe, anticipated practical barriers, and felt responsible for the collective. On the contrary, perceiving vaccination as unnecessary and weighing the benefits and risks of vaccination was related to lower support. Older individuals and males more often endorsed vaccination mandates than did younger participants and females. Interestingly, there was a gap between vaccination intentions and support for mandates, showing that the attitude toward mandatory vaccination was not only determined by vaccination-related factors such as vaccine safety or prosocial considerations.

CONCLUSIONS

Because of low public support, mandatory vaccination against COVID-19 should be considered a measure of last resort in Germany. However, if removing barriers to vaccination and educational campaigns about vaccine safety and the societal benefits of high vaccination uptake are not sufficient for increasing vaccination uptake to the required levels, mandates could be introduced. In this case, measures to ensure and increase acceptance and adherence should be taken.

Associations of individual factors and early childhood education and care (ECEC) centres characteristics with preschoolers' BMI in Germany

Background

The number of obese children is rising worldwide. Many studies have investigated single determinants of children’s body mass index (BMI), yet studies measuring determinants at different potential levels of influence are sparse. The aim of this study is to investigate the independent role of parental socioeconomic position (SEP), additional family factors at the micro level, as well as early childhood education and care (ECEC) centre characteristics at the meso level regarding BMI.

Methods

Analyses used the baseline data of the PReschool INtervention Study (PRINS) including up to 1,151 children from 53 ECEC centres. Multi-level models first estimated the associations of parental SEP indicators (parental school education, vocational training, and household income) with the children’s standard deviation scores for BMI (SDS BMI, standardised for age and gender). Second, structural (number of siblings), psychosocial (strained family relationships), and nutrition behavioural (soft-drink consumption, frequency of fast-food restaurant visits) family factors at the micro level were included. Third, characteristics of the ECEC centre at the meso level in terms of average group size, the ratio of overweight children in the group, ECEC centre type (all-day care), and the location of the ECEC centre (rural vs urban) were included. All analyses were stratified by gender and adjusted for age, migration background, and parental employment status.

Results

Estimates for boys and girls appeared to differ. In the full model, for boys the parental SEP indicators were not related to SDS BMI. Factors related to SDS BMI in boys were: two or more siblings; B = -.55; p = 0.045 [ref.: no sibling]), the characteristics of the ECEC centre in terms of average group size (20 – 25 children; B = -.54; p = 0.022 [ref.: < 20 children]), and the ratio of overweight children (more overweight children B = -1.39; p < 0.001 [ref.: few overweight children]). For girls the number of siblings (two and more siblings; B = .67; p = 0.027 [ref.: no sibling]) and average group size (> 25 children; B = -.52; p = 0.037 [ref.: < 20 children]) were related to SDS BMI.

Conclusions

The BMI of preschool children appears to be associated with determinants at the micro and meso level, however with some gender differences. The identified factors at the micro and meso level appear largely modifiable and can inform about possible interventions to reduce obesity in preschool children.

Assessing the extent of shared decision making in Pediatrics: Preliminary psychometric evaluation of the German CollaboRATEpediatric scales for patients aged 7-18 years, parents and parent-proxy reports

OBJECTIVE

To conduct a preliminary evaluation of psychometric properties of CollaboRATE^pediatric, a set of three scales to assess shared decision making (SDM) with pediatric patients, parents and parents on behalf of their children (parent-proxy reports). As secondary objectives we examined the scales' distributional characteristics, acceptability, and agreement between scales.

METHODS

Patients aged ≥ 7 years and parents were recruited in two outpatient facilities providing healthcare services for children with neurological and behavioral health conditions. We collected 46, 169 and 227 pediatric patient, parent-proxy and parent reports, respectively. Convergent, divergent and discriminative validity were investigated. Acceptability of the scales and agreement between patient and parent-proxy reports were explored by assessing item nonresponse and Bland-Altman plots.

RESULTS

While convergent and divergent validity were established for the parent scale, discriminative validity was not demonstrated for any of the scales. The scales showed good to excellent acceptability. Parent-proxy reports agreed to a moderate extent with patients' self-reports of SDM.

CONCLUSION

CollaboRATE^pediatric offers a starting point for parsimoniously assessing SDM in Pediatrics, however further psychometric testing is warranted.

PRACTICE IMPLICATIONS

Given limited psychometric support for the pediatric patient scale, we recommend using both the pediatric patient and parent-proxy report scales to assess SDM in pediatric patients until further psychometric testing is concluded.

[Impact of wearing face masks in public to prevent infectious diseases on the psychosocial development in children and adolescents: a systematic review]

Hintergrund

Zur Prävention tröpfchenübertragener Infektionskrankheiten wird das Tragen einer Maske im öffentlichen Raum unter bestimmten Bedingungen empfohlen.

Ziel der Arbeit

Ziel war, über eine sensitive Literatursuche möglichst alle deutsch- und englischsprachigen Forschungsergebnisse aus begutachteten Fachzeitschriftenartikeln zu den Auswirkungen des Masketragens zur Prävention von Infektionen auf die psychosoziale Entwicklung von Kindern und Jugendlichen zusammenzutragen.

Methoden

Es wurde ein systematischer Review unter Berücksichtigung verschiedener Studiendesigns durchgeführt (Suchzeitraum bis einschließlich 12.07.2021). Das Verzerrungsrisiko der Studien wurde mit einem Risk-of-Bias-Verfahren ermittelt. Es fand eine deskriptiv-narrative Ergebnissynthese statt.

Ergebnisse

Es wurden 13 Studien eingeschlossen, wobei das Gesamtverzerrungsrisiko in allen Primärstudien als hoch eingeschätzt wurde. Es gibt Hinweise aus Befragungsstudien, dass die Fähigkeit zum Lesen der Mimik von Kindern/Jugendlichen und/oder ihren Betreuer:innen im (Vor‑)Schulsetting durch das Masketragen als beeinträchtigt erlebt wird, die durch mehrere Experimentalstudien bestätigt wurden. 2 Studien berichteten über psychische Symptome wie Ängste oder Stresserleben sowie Konzentrations- und Lernschwierigkeiten durch das Masketragen während der COVID-19-Pandemie. Eine Studie während der SARS-Pandemie 2002/2003 untersuchte mündliche Prüfungsleistungen in Englisch als Fremdsprache und zeigte keinen Unterschied zwischen den Bedingungen „Maske“ versus „keine Maske“.

Diskussion

Zu den Auswirkungen des Masketragens auf verschiedene Entwicklungsbereiche von Kindern und Jugendlichen lassen sich basierend auf der unzureichenden Studienlage nur wenige Erkenntnisse ableiten. Es fehlen Forschungsdaten zu den Folgen für die Endpunkte psychische Entwicklung, Sprachentwicklung, sozioemotionale Entwicklung, soziales Verhalten, Schulerfolg und Teilhabe. Weitere qualitative Studien und epidemiologische Studien sind unbedingt nötig.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03443-5) enthalten.

The four weeks before lockdown during the COVID-19 pandemic in Germany: a weekly serial cross-sectional survey on risk perceptions, knowledge, public trust and behaviour, 3 to 25 March 2020

BackgroundDuring the COVID-19 pandemic, public perceptions and behaviours have had to adapt rapidly to new risk scenarios and radical behavioural restrictions.AimTo identify major drivers of acceptance of protective behaviours during the 4-week transition from virtually no COVID-19 cases to the nationwide lockdown in Germany (3-25 March 2020).MethodsA serial cross-sectional online survey was administered weekly to ca 1,000 unique individuals for four data collection rounds in March 2020 using non-probability quota samples, representative of the German adult population between 18 and 74 years in terms of age × sex and federal state (n = 3,910). Acceptance of restrictions was regressed on sociodemographic variables, time and psychological variables, e.g. trust, risk perceptions, self-efficacy. Extraction of homogenous clusters was based on knowledge and behaviour.ResultsAcceptance of restrictive policies increased with participants' age and employment in the healthcare sector; cognitive and particularly affective risk perceptions were further significant predictors. Acceptance increased over time, as trust in institutions became more relevant and trust in media became less relevant. The cluster analysis further indicated that having a higher education increased the gap between knowledge and behaviour. Trust in institutions was related to conversion of knowledge into action.ConclusionIdentifying relevant principles that increase acceptance will remain crucial to the development of strategies that help adjust behaviour to control the pandemic, possibly for years to come. Based on our findings, we provide operational recommendations for health authorities regarding data collection, health communication and outreach.

Willingness to bear economic costs of measures against SARS-CoV-2 in Germany

Background

The aim of this study was to assess the willingness of the general population in Germany to bear the economic costs of measures against the spread of SARS-CoV-2.

Methods

Repeated cross-sectional data were taken from three waves of a nationally representative survey of individuals aged 18 to 74 years (wave 8: 21–22 April 2020, N = 976; wave 16: 7–8 July 2020, N = 977; wave 38: 9–10 March 2021). The willingness to accept a reduction of annual household income in order to bear the economic costs of the measures against SARS-CoV-2 served as outcome measure. Two-part models were used including explanatory variables on sociodemographic and (subjectively assessed) potential health hazard caused by COVID-19.

Results

65.5% (61.6%; 56.9%) of respondents in wave 8 (wave 16; wave 38) were willing to accept a reduction of income, with the likelihood for accepting a reduction of income being positively associated with higher affect (i.e. emotional reaction) and presumed severity regarding COVID-19 in all three waves. The mean maximum percentage of income participants were willing to give up was 3.3% (95% CI: 2.9 to 3.7%) in wave 8, 2.9% (95% CI: 2.5 to 3.3%) in wave 16 and 4.3% (95% CI: 3.6 to 5.0%) in wave 38, with presumed severity of COVID-19 being positively associated with this percentage in all three waves.

Conclusions

The majority of respondents indicated willingness to sacrifice income in order to bear the costs of measures against the spread of SARS-CoV-2, with the potential health hazard caused by COVID-19 being consistently associated with this willingness. However, the proportion of individuals who were willing to give up income slightly decreased throughout the pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11734-4.

Sociodemographic characteristics determine download and use of a Corona contact tracing app in Germany-Results of the COSMO surveys

During the SARS-CoV-2 pandemic mobile health applications indicating risks emerging from close contacts to infected persons have a large potential to interrupt transmission chains by automating contact tracing. Since its dispatch in Germany in June 2020 the Corona Warn App has been downloaded on 25.7 Mio smartphones by February 2021. To understand barriers to download and user fidelity in different sociodemographic groups we analysed data from five consecutive cross-sectional waves of the COVID-19 Snapshot Monitoring survey from June to August 2020. Questions on the Corona Warn App included information on download, use, functionality, usability, and consequences of the app. Of the 4,960 participants (mean age 45.9 years, standard deviation 16.0, 50.4% female), 36.5% had downloaded the Corona Warn App. Adjusted analysis found that those who had downloaded the app were less likely to be female (Adjusted Odds Ratio for men 1.16 95% Confidence Interval [1.02;1.33]), less likely to be younger (Adjusted Odds Ratio for age 18 to 39 0.47 [0.32;0.59] Adjusted Odds Ratio for age 40 to 64 0.57 [0.46;0.69]), less likely to have a lower household income (AOR 0.55 [0.43;0.69]), and more likely to live in one of the Western federal states including Berlin (AOR 2.31 [1.90;2.82]). Willingness to disclose a positive test result and trust in data protection compliance of the Corona Warn App was significantly higher in older adults. Willingness to disclose also increased with higher educational degrees and income. This study supports the hypothesis of a digital divide that separates users and non-users of the Corona Warn App along a well-known health gap of education, income, and region.

Determinants of Postponed Cancer Screening During the COVID-19 Pandemic: Evidence from the Nationally Representative COVID-19 Snapshot Monitoring in Germany (COSMO)

Purpose

The COVID-19 pandemic is accompanied by various challenges for individual health and the health care system. However, preventive examinations such as cancer screenings should not be postponed during a pandemic. Because nationally representative studies describing postponed cancer screenings and identifying its determinants in Germany are lacking, our aim was to close this gap in knowledge.

Materials and Methods

We used cross-sectional data from the nationally representative online-survey “COVID-19 Snapshot Monitoring in Germany (COSMO)” (wave 17), which was conducted in July 2020. The analytical sample included 974 individuals (mean age was 45.9 years, SD: 16.5 years; 18 to 74 years). The outcome measure was whether cancer screening had been postponed since March 2020 due to the COVID-19 pandemic (no, attended as planned; yes, postponed).

Results

In total, slightly more than 10% of individuals stated to have postponed cancer screenings between March and July 2020 due to the COVID-19 pandemic, particularly women and individuals aged 30 to 49 years. The likelihood of postponed cancer screening was positively associated with higher affect regarding COVID-19 (OR: 1.65, 95% CI: 1.16–2.35), whereas it was negatively associated with younger age (eg, 18 to 29 years, OR: 0.17, 95% CI: 0.05–0.64, compared to individuals 30 to 49 years).

Conclusion

Study findings showed that one out of ten individuals postponed cancer screenings during the COVID-19 pandemic. We determined two correlates of them (age and affect regarding COVID-19). Individuals with an increased likelihood of postponed cancer screenings should be specifically addressed.

Differences in risk perception, knowledge and protective behaviour regarding COVID-19 by education level among women and men in Germany. Results from the COVID-19 Snapshot Monitoring (COSMO) study

The main strategy for combatting SARS-CoV-2 infections in 2020 consisted of behavioural regulations including contact reduction, maintaining distance, hand hygiene, and mask wearing. COVID-19-related risk perception and knowledge may influence protective behaviour, and education could be an important determinant. The current study investigated differences by education level in risk perception, knowledge and protective behaviour regarding COVID-19 in Germany, exploring the development of the pandemic over time. The COVID-19 Snapshot Monitoring study is a repeated cross-sectional online survey conducted during the pandemic in Germany from 3 March 2020 (waves 1-28: 27,957 participants aged 18-74). Differences in risk perception, knowledge and protective behaviour according to education level (high versus low) were analysed using linear and logistic regression. Time trends were accounted for by interaction terms for education level and calendar week. Regarding protective behaviour, interaction terms were tested for all risk perception and knowledge variables with education level. The strongest associations with education level were evident for perceived and factual knowledge regarding COVID-19. Moreover, associations were found between low education level and higher perceived severity, and between low education level and lower perceived probability. Highly educated men were more worried about COVID-19 than those with low levels of education. No educational differences were observed for perceived susceptibility or fear. Higher compliance with hand washing was found in highly educated women, and higher compliance with maintaining distance was found in highly educated men. Regarding maintaining distance, the impact of perceived severity differed between education groups. In men, significant moderation effects of education level on the association between factual knowledge and all three protective behaviours were found. During the pandemic, risk perception and protective behaviour varied greatly over time. Overall, differences by education level were relatively small. For risk communication, reaching all population groups irrespective of education level is critical.

[Promotion of physical activity among the elderly as an example of knowledge translation: How do scientific findings enter community practice?]

BACKGROUND

Scientific findings can be an important source of knowledge for public health stakeholders involved in promoting physical activity, but several barriers hinder their use. Knowledge translation can simplify this process, but it requires the understanding of the stakeholder's needs.

OBJECTIVES

This qualitative study aims to describe how public health stakeholders access information and scientific findings, identify possible barriers, and highlight the needs of stakeholders in terms of presentation and processing.

MATERIALS AND METHODS

Semi-structured interviews were conducted with twelve local- and state-level stakeholders from North Rhine-Westphalia, Saxony-Anhalt, and Thuringia working in the area of physical activity promotion. The interviewees were selected through purposive sampling. The interviews were evaluated using qualitative content analysis.

RESULTS

The benefits of scientific findings are emphasized by the interviewees, but a lack of resources in combination with a flood of information, high complexity, and technical jargon complicate their application. There is a need for tailored preparation in the form of summaries, filter functions, elaboration of practice-relevant elements, and ways of provision.

CONCLUSIONS

To achieve successful knowledge translation, collaboration and interactive exchange between researchers, policymakers, and practice as well as a demand-oriented processing of scientific findings are central. Networking and bundling of knowledge on a platform are important tasks for the future.

Implementation of evidence-based health promotion and disease prevention interventions: theoretical and practical implications of the concept of transferability for decision-making and the transfer process

Evidence-based health promotion and disease prevention require incorporating evidence of the effectiveness of interventions into policy and practice. With the entry into force of the German Act to Strengthen Health Promotion and Prevention (PrävG), interventions that take place in people’s everyday living environments have gained in importance. Decision-makers need to assess whether an evidence-based intervention is transferable to their specific target context. The Federal Centre for Health Education (BZgA) recommends that transferability of an intervention should be clarified before any decision to implement it. Furthermore, transferability needs to be finally determined after an evaluation in the target context. In this article, we elaborate on theoretical and practical implications of the concept of transferability for health promotion and disease prevention based on the Population–Intervention–Environment–Transfer Models of Transferability (PIET-T). We discuss how decision-makers can anticipate transferability prior to the intervention transfer with the help of transferability criteria and how they can take transferability into account in the further process. This includes the steps of the analysis of a health problem and identification of effective interventions, the steps of the initial transferability assessment and identification of the need for adaptation, and the steps of the implementation and evaluation. Considering transferability is a complex task that comes with challenges. But it offers opportunities to select a suitable intervention for a target context and, in the transfer process, to understand the conditions under which the intervention works in this context. This knowledge helps to establish an evidence base, which is practically relevant.

[Establishing evidence-based prevention and health promotion: criteria for evidence-based interventions and necessary organizational requirements and capacities]

Für die Umsetzung des Präventionsgesetzes in einem sich entwickelnden System Prävention und Gesundheitsförderung (PGF) ist die Anforderung der Evidenzbasierung formuliert. Vor diesem Hintergrund stellt sich die Frage, welche Schritte, Prozesse und Vorgehensweisen in diesem System benötigt werden, um der Anforderung zunehmend gerecht zu werden. Dieser Übersichtsartikel diskutiert für Deutschland, wie evidenzbasierte Maßnahmen in der Praxis operationalisiert werden können und welche organisationalen Rahmenbedingungen und Kapazitäten für ein evidenzbasiertes Handeln von AkteurInnen notwendig sind.

Aufbauend auf internationalen wissenschaftlichen Erkenntnissen und dem Memorandum Evidenzbasierte Prävention und Gesundheitsförderung der Bundeszentrale für gesundheitliche Aufklärung (BZgA) wird zunächst das Verständnis von evidenzbasierten Maßnahmen erläutert und im Weiteren werden Elemente zur Umsetzung von mehr Evidenzbasierung skizziert.

Neben der transparenten und einheitlichen Darstellung in Datenbanken und Empfehlungen ist es notwendig, bei EntscheidungsträgerInnen in Praxis und Politik ein gemeinsames Verständnis von evidenzbasierten Interventionen und von Anforderungen für eine Evaluation, die Evidenzbasierung sichert, zu schaffen. Darüber hinaus kann evidenzbasiertes Handeln von EntscheidungsträgerInnen gefördert werden durch Wertschätzung gegenüber Evidenzbasierung in ihren Organisationen, durch Gewährleistung eines regelhaften Zugangs zu Evidenzdatenbanken, durch verbesserte Kompetenzen in Bezug auf Interpretation von Evidenz und durch eine systematische Zusammenarbeit mit der Wissenschaft.

Mehr Evidenzbasierung ist eine Voraussetzung für die nachhaltige Verankerung von PGF als fünfte Säule des Gesundheitssystems.

Assessment of shared decision making in pediatrics: Developing German scales for patients aged 7-18 years, parents and parent-proxy reports (CollaboRATEpediatric)

OBJECTIVE

To develop parsimonious German scales (CollaboRATE^pediatric) to assess shared decision making (SDM) with patients aged 7-18 years, parents and parents on behalf of their children (parent-proxy reports), and to establish comprehensibility and preliminary face validity.

METHODS

Based on an existing SDM scale for adults (CollaboRATE) we developed CollaboRATE^pediatric in a two-step approach: (1) team-based translation of the English CollaboRATE scale into German and adaptation for pediatric patients, parents and parent-proxy reports, followed by (2) iterative revisions of the CollaboRATE^pediatric scales based on cognitive interviews with patients and parents until comprehensibility and preliminary face validity were established.

RESULTS

Taking into account seven problem areas identified in four rounds of cognitive interviews (e.g., item complexity) we developed CollaboRATE^pediatric scales for patients, parents and parent-proxy reports. By iteratively revising items we were able to resolve all problem areas and achieved full comprehensibility and intended interpretation of all items.

CONCLUSION

The scales enable the parsimonious assessment of SDM with pediatric patients and parents as well as comparisons between the two groups. Future empirical work will establish the psychometric performance of CollaboRATE^pediatric.

PRACTICE IMPLICATIONS

CollaboRATE^pediatric can be used in quality improvement initiatives to foster the comprehensive implementation of SDM in pediatrics.

[Demand-driven communication strategy of the Federal Centre for Health Education (BZgA) during the COVID-19 pandemic]

With the declaration of a pandemic situation of national significance by the German Bundestag, the Federal Centre for Health Education (BZgA) is fulfilling its task of providing information for understanding the pandemic situation and implementing the necessary protective measures in a clear manner throughout Germany within the framework of the adapted National Pandemic Plan COVID-19. The BZgA targets its information according to the needs of specific groups and actively involves multipliers.In order to incorporate the perspectives of the population as well as those of prevention and health promotion professionals into the services developed by the BZgA, given the particularly initial low level of knowledge in the population, various methods and data sources were used: the COVID-19 Snapshot Monitoring (COSMO) population survey, the monitoring of citizens' enquiries via telephone and e‑mail to the BZgA, surveys of counselling professionals from nationwide telephone and online counselling centres, surveys of health professionals in early help (NZFH) and interdisciplinary practice expert hearings. Beyond providing pure information, practical and everyday offers should be developed and provided according to WHO guidelines and evidence-based criteria of effective communication in order to support the competences for a gradual adaptation to a "new normality".The paper describes the data-based and evidence-informed development process of communication content and offers, their dissemination via existing websites and channels for other topics as well as their integration into the new online platform www.zusammengegencorona.de . This demonstrates how demand-driven and target group-specific communication offers can be implemented beyond the classic and proven campaign appearance.

[Public trust in institutions in the first half of the Corona pandemic: findings from the COVID-19 Snapshot Monitoring (COSMO) project]

Hintergrund

In der Coronaviruspandemie nehmen 2 Institutionen eine zentrale Rolle in der evidenzbasierten Einordnung des Geschehens für Politik und Bevölkerung ein. Das Robert Koch-Institut (RKI) koordiniert die Pandemiebekämpfung, erstellt fundierte Empfehlungen für medizinisches Fachpersonal, die Medien sowie die Bevölkerung und berät die Politik. Die Bundeszentrale für gesundheitliche Aufklärung (BZgA) informiert die Bevölkerung und Institutionen.

Ziel der Arbeit

Mit dem COVID-19 Snapshot Monitoring (COSMO) wird beobachtet, ob und wie sich das Vertrauen in Institutionen über die Pandemie verändert. Es wird untersucht, welche Bevölkerungsgruppen Vertrauen zeigen und wie dies mit Einstellungen, Risikowahrnehmung und Verhaltensweisen zusammenhängt.

Material und Methoden

In Querschnittstudien werden seit März 2020 die Risikowahrnehmung, das Verhalten und die Akzeptanz von Maßnahmen sowie das Vertrauen in Institutionen mit etwa N = 1000 Befragten pro Erhebung untersucht.

Ergebnisse

Das Vertrauen in RKI und BZgA war generell hoch, sank aber über den Verlauf der Pandemie. Höheres Vertrauen ging für beide Institutionen mit höherem Alter der Befragten, höherer Bildung, höherer Risikowahrnehmung und höherer Akzeptanz von Maßnahmen einher.

Verhaltensweisen wie Abstandhalten und Händewaschen wurden häufiger gezeigt. Männer und chronisch Erkrankte zeigten geringeres Vertrauen.

Diskussion

Die Ergebnisse zeigen, dass Vertrauen weiter gefördert werden sollte. Dies könnte u. a. erreicht werden, indem in der Entwicklung und Begründung von Strategien und Maßnahmen auch die Sichtweise der Bevölkerung (z. B. durch COSMO) berücksichtigt wird. Kommunikationsstrategien und Handlungsempfehlungen sollten darauf abzielen, Personen mit hoher Risikowahrnehmung zu unterstützen und zu entlasten.

Physical Activity during COVID-19 in German Adults: Analyses in the COVID-19 Snapshot Monitoring Study (COSMO)

The novel coronavirus (COVID-19) and the resulting outbreak response measures in Germany and worldwide led to severe limitations in everyday life. This affected all sorts of daily activities and the possibility for physical activity (PA), which represents a major coping strategy against stress. The objective of this study was to analyse PA in German adults during a total lockdown phase including school closures in April 2020 in certain subgroups and in relation to other coping strategies. Data from the COVID-19 Snapshot Monitoring (COSMO) survey, an online cross-sectional study with 1034 participants between 18 and 74 years, were utilised (14/15 April 2020). In addition to descriptive analyses, the odds of performing PA according to the World Health Organization (WHO) recommendations for adults (at least 2.5 h/week of at least moderate intensity) were analysed by univariate and multivariate logistic regression analyses. In total, 440 (42.6%) participants fulfilled this criterion. Participants with children <6 years were less likely to meet the WHO recommendation (OR = 0.51; 95% CI: 0.33-0.78), while those with a higher level of education, good coping behaviour, regular alcohol consumption, and being satisfied with life were more likely to meet the WHO recommendation. In conclusion, PA intervention strategies tailored to specific vulnerable subgroups such as individuals with low educational background and parents with young children are needed in future pandemic response.

Perceptions of Health Care Use in Germany during the COVID-19 Pandemic

This paper examined the determinants of perceived access to health care use during the COVID-19 pandemic in Germany using data from two waves (8 and 16) of the COVID-19 Snapshot Monitoring (COSMO). Descriptive and regression analysis were used. In wave 8, we found that about 60% of the individuals rather disagreed about having had problems accessing medical care. Furthermore, 73% of the individuals rather disagreed to having experienced health deteriorations due to restrictions on the availability of medical care. Moreover, 85% of the individuals were rather optimistic about future access to healthcare services. Overall, slightly better past and future access to healthcare services has been reported in wave 16. Several determinants were identified in regression analysis. In conclusion, data suggest that perceived past and future access to healthcare services during the COVID-19 pandemic is reasonably good.

Impact of the COVID-19 pandemic and the related containment measures on the mental health of children and adolescents

Children and adolescents are particularly affected by the COVID-19 pandemic and the official containment measures. However, the effects on their mental health have been little studied. The aim of this narrative review is to summarize existing evidence on the mental health of children and adolescents in the first weeks of the COVID-19 pandemic and during the measures taken to contain it in Germany. First international and national studies draw a differential picture. Children and adolescents showed symptoms of anxiety and depression as well as a reduced quality of life. The closure of childcare and educational facilities and the associated loss of the familiar daytime structure as well as loss of contact and independent learning at home posed considerable challenges for affected children and their families. Spatial confinement at home and the lack of alternative options of stay during the containment measures could also have lead to increased family stress, heightened family aggression, and domestic violence. However, the findings of several studies also show that many families coped with the time during the containment measures mostly well. In the event of possible future pandemics or further waves of the COVID-19 pandemic, the needs of adolescents and their families during the containment measures should be given greater consideration.

Impact of the COVID-19 pandemic and the related containment measures on the mental health of children and adolescents

Children and adolescents are particularly affected by the COVID-19 pandemic and the official containment measures. However, the effects on their mental health have been little studied. The aim of this narrative review is to summarize existing evidence on the mental health of children and adolescents in the first weeks of the COVID-19 pandemic and during the measures taken to contain it in Germany. First international and national studies draw a differential picture. Children and adolescents showed symptoms of anxiety and depression as well as a reduced quality of life. The closure of childcare and educational facilities and the associated loss of the familiar daytime structure as well as loss of contact and independent learning at home posed considerable challenges for affected children and their families. Spatial confinement at home and the lack of alternative options of stay during the containment measures could also have lead to increased family stress, heightened family aggression, and domestic violence. However, the findings of several studies also show that many families coped with the time during the containment measures mostly well. In the event of possible future pandemics or further waves of the COVID-19 pandemic, the needs of adolescents and their families during the containment measures should be given greater consideration.

Psychometric properties and contextual appropriateness of the German version of the Early Development Instrument

BACKGROUND

Assessing the early development of children at a population level in educational settings, may be useful for public health and policy decision making. In this study, we evaluated the psychometric properties and the contextual appropriateness of a German language version of the Early Development Instrument (EDI), a survey-based instrument originally developed in Canada, which assesses developmental vulnerability for children in preschool settings.

METHODS

Sixty preschool teachers from six preschool organizations (22% of organizations contacted) in three cities in southwest Germany participated. They administered a German version of the EDI (GEDI) to 225 children (51% of eligible children). We assessed internal consistency, test-retest and interrater reliability. Preschool teachers assisted in determining face-validity by reviewing item coverage and comprehensibility. Exploratory factor analysis (EFA) was used to evaluate convergent validity. Concurrent validity was measured using correlations and agreements (Bland-Altman plots) between GEDI and other validated instrument scores. Additionally, we compared associations between GEDI domain scores and sociodemographic characteristics with similar associations in EDI studies worldwide.

RESULTS

GEDI domains showed good to excellent internal consistency (0.73 < α > 0.99) and moderate to good test-retest and interrater reliability (0.50 to 0.81 and 0.48 to 0.71, respectively [p-value < 0.05]). Face validity was considered acceptable. EFA showed a factor structure similar to the original EDI. Correlations (range: 0.32 to 0.67) and agreements between GEDI scores and other German language instruments suggested good external reliability. Scoring within the lowest 10th percentile was strongly associated with age.

CONCLUSIONS

Our psychometric assessment suggests good reliability and consistency of the GEDI. Differences in the age distribution of children, pedagogical objectives and educational system features of German preschools require future work to determine score thresholds indicative of vulnerability. Aside from dropping selected items from the original EDI that were inconsistent with features of the German educational system, the distribution of values in the language and cognitive development domain also suggested that context-specific cut-offs must be established for the German version. Such efforts are needed to account for relevant contextual differences between the educational systems.

Measuring social participation in children with chronic health conditions: validation and reference values of the child and adolescent scale of participation (CASP) in the German context

Background

While ICF-CY-based models of care are promising avenues for improving participation of children with chronic health conditions, feasible and valid instruments to assess participation as an outcome in routine are still needed. We aimed to validate a German parent-report version of the Child and Adolescent Scale of Participation (CASP) in children with chronic health conditions of different severity.

Methods

Cross-sectional data were collected in 327 children (mean age 7.8 years, 55% boys) from two paediatric centres (n = 112) and one population-based sample (n = 215). Cronbach’s alpha, factor analyses, face validity assessments, correlation analyses, receiver operating characteristics (ROC) curves, and parent-reported health-related quality of life (HRQoL: KINDL) were used to examine internal consistency, test-retest reliability, and capacity to differentiate between disease severity groups. Disease severity was operationalized according to ICD-diagnosis groups and/or parent-reports on health problems, medical and educational support, and medication. A newly developed item “overall perceived participation” was added to the CASP and evaluated.

Results

We found good to excellent content validity, excellent internal consistency, and good-to-excellent test-retest reliability of the instrument. While children with mild disease had a significantly greater extent of participation (higher CASP scores) than children with severe disease, they did not differ from healthy children. Children with mild compared to severe disease much more differed in participation as measured by the CASP compared to the KINDL (area under the ROC curve: 0.92 vs. 0.75). In addition, the item “overall perceived participation” was highly correlated (r = 0.86) with the CASP total score, indicating the potential value of this specific single item. Finally, we provided preliminary reference values for the CASP obtained in a population-based sample of children without chronic health conditions.

Conclusions

The German version of the CASP and the new item are efficient, valid and reliable measures of social participation in childhood. The CASP-measured participation focuses more on attendance than on involvement into social circumstances of everyday life. To detect children with a high burden of disease on everyday life, the CASP may be more accurate than HRQoL instruments such as the KINDL. As outcome measurement, the CASP may facilitate the implementation of patient-centred paediatric health care.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1495-6) contains supplementary material, which is available to authorized users.

Deformational plagiocephaly: The case for an evolutionary mismatch

Lay Summary: In industrialized societies some babies develop flattening of the back part of their head. It is thought that this comes from sleeping supine, which has been shown to be the safest option for babies. However, this explanation cannot be correct from an evolutionary standpoint: why should safe sleep come at the cost of a misshaped head?

Babies in industrialized societies are generally healthy. The medical problems they may be afflicted with are usually well understood. Deformational plagiocephaly presents a notable exception. In many industrialized countries, one in six babies shows posterior flattening of the skull—a feature noteworthy from an evolutionary perspective as the well rounded cranium is part of the ‘Kindchenschema’ evolved to secure care for the infant. It is commonly held that the deformation of the posterior cranium occurs as a consequence of the supine sleep position, now advocated as the safest sleep position for babies by medical experts. This explanation, however, does not fare well in the light of evolutionary theory: why should safe sleep come at the cost of a social handicap? Here, we present an alternative hypothesis that is grounded on evolutionary mismatch theory and exemplifies how evolutionary reasoning can help clarify medical conditions relevant to today’s public health.

Subjectively and Objectively Assessed Behavioral, Social, and Physical Environmental Correlates of Sedentary Behavior in Preschoolers

OBJECTIVE

To investigate associations between preschoolers' objective leisure-time sedentary behavior and a comprehensive set of subjective and objective potential correlates of sedentary behavior across the behavioral, social, and physical environmental domains on both the family and community level.

STUDY DESIGN

In 3- to 6-year-old preschoolers (n = 738) from 52 preschools in Southern Germany, leisure time spent in sedentary behavior was assessed by accelerometry in 2008-2009. Family- and community-level potential correlates of sedentary behavior from different domains (behavioral, social, and physical environmental) were subjectively (ie, by parent-proxy report) and objectively (ie, by routine administrative data) assessed.

RESULTS

None of the objective social and physical environmental correlates showed associations with sedentary behavior. Leisure-time sedentary behavior decreased with greater levels of moderate-to-vigorous physical activity (both weekends and weekday afternoons), participation in organized sports, parental leisure-time physical activity, as well as greater parental traffic safety perceptions (weekends only).

CONCLUSIONS

Targeting multiple health behaviors at the same time (ie, physical activity and sedentary behavior) and focusing on the entire family (ie, preschoolers, parents, and potentially older siblings) might be useful opportunities to reduce sedentary behaviors in preschoolers.

Subjectively and objectively assessed social and physical environmental correlates of preschoolers' accelerometer-based physical activity

BACKGROUND

Overweight and low levels of physical activity (PA) in preschoolers are major public health concerns. However, to date only few studies have investigated subjective and objective correlates of PA across different socioecological domains in preschoolers. We therefore simultaneously investigate associations between preschoolers' objectively measured leisure-time PA and a comprehensive set of subjective and objective potential PA correlates across the behavioral, social and physical environmental domains on both family- and community-level.

METHODS

In this cross-sectional study time spent in moderate-to-vigorous PA (MVPA) and total PA (TPA) were measured by combined accelerometry and heart rate monitoring in 735 3-6 year-old children from 52 preschools in Southern Germany. Family- and community-level potential correlates of PA from different domains (behavioral, social and physical environmental) were subjectively (i.e. by parent proxy-report) and objectively assessed. Their associations with PA on weekend days and weekday afternoons were tested by covariate-adjusted multilevel regression models.

RESULTS

While none of the objective social and physical environmental factors showed associations with PA, subjective parental traffic safety perceptions were positively associated with MVPA and TPA on weekends. Also, preschoolers' participation in organized sports was positively correlated with MVPA (on weekends) and TPA (both on weekends and weekday afternoons).

CONCLUSION

Subjective traffic safety perceptions and participation in organized sports, an indicator and a result of parental support towards PA - i.e. subjective parental perceptions of environmental factors and family-level correlates which are more proximal to preschoolers - might be more central to PA in preschool age than objectively assessed community-level environmental features which tend to be more distal correlates. If replicable, targeting parental perceptions of environmental factors and parental support for PA in preschool age might be powerful leverages for public health policy.

Contextual influences on physical activity and eating habits -options for action on the community level

Background

This conceptual paper aims to illustrate the ways in which communities are able to advance health improvements on a population level. Outcome measures may include increased physical activity and healthier eating habits in particular, as well as an improved health-related quality of life and social cohesion as more generic outcomes.

Main body

The paper begins by asking initial questions: Why did previous health-specific interventions only show moderate effects on an individual level and mixed effects on a population level? What is the added value of a community-based public health perspective compared to the traditional biomedical perspective when it comes to prevention? Why are we living the way we are living? Why do we eat what we eat? Why do we move the way we move?

Subsequently, we illustrate the broad spectrum of contextual interventions available to communities. These can have geographical and technological as well as economic, political, normative and attitude-specific dimensions. It is shown that communities have a strong influence on health-related contexts and decision-making of adults, adolescents and children. In addition contextual characteristics, effects, mediators, moderators and consequences relevant for health can differ greatly between age groups. Both small-scale settings and overarching sectors possess physical, economic, political and sociocultural characteristics that can be proactively influenced by community decision-makers in the sense of a “health in all policies”-strategy.

Short conclusion

After presenting various interdisciplinary approaches to community-based health interventions, the manuscript closes with the following core message: Successful community-based health promotion strategies consist of multilevel – multicomponent interventions on the micro, meso and macro-level-environments.

Deformational plagiocephaly in normal infants: a systematic review of causes and hypotheses

BACKGROUND

Deformational plagiocephaly (DP) is one of the most prevalent abnormal findings in infants and a frequent reason for parents to seek paediatric advice.

OBJECTIVE

To systematically review the literature and identify evidence and hypotheses on the aetiology and determinants of DP in otherwise healthy infants.

DESIGN

Systematic keyword search in all major biomedical databases to identify peer-reviewed publications reporting (a) empirical research or (b) hypotheses on the aetiology of DP in healthy, term infants. 3150 studies published between 1985 and 2016 and containing relevant keywords were screened. In a two-pronged approach, results were summarised separately for the body of empirical work (22 studies) and the body of hypotheses (110 articles).

REVIEW FINDINGS

Only a few empirical studies have examined risk factors in non-selected patient populations on a higher grade methodological level. The most commonly reported risk factors were: male gender, supine sleep position, limited neck rotation or preference in head position, first-born child, lower level of activity and lack of tummy time. Agreement between empirical studies was poor for most exposures, including supine sleep position, tummy time and use of car seats. The articles reporting hypotheses on the aetiology of DP cover a wide field of environmental and biological factors, but include little suggestions as to the potential influence of the everyday care environment of the baby.

CONCLUSIONS AND RELEVANCE

The evidence on the aetiology of DP is fragmentary and heterogeneous. In addition, factors possibly relevant to the development of DP have not been appreciated in the scientific discussion.

Predictive value of General Movement Assessment for preterm infants' development at 2 years - implementation in clinical routine in a non-academic setting

BACKGROUND

General movements (GM) are used in academic settings to predict developmental outcome in infants born preterm. However, little is known about the implementation and predictive value of GM in non-academic settings.

AIMS

The aim of this study is twofold: To document the implementation of GM assessment (GMA) in a non-academic setting and to assess its predictive value in infants born preterm.

METHODS AND PROCEDURES

We documented the process of implementing GMA in a non-academic outpatient clinic. In addition, we assessed the predictive value of GMA at 1 and 3 months' corrected age for motor and cognitive development at 2 years in 122 children born <33 weeks' gestation. Outcome at two years was based upon the Bayley Scales of Infant Development-II (mental/psychomotor developmental index (MDI, PDI)) and a neurological examination. The infants' odds of atypical outcome (MDI or PDI ≤70 or diagnosis CP) and the predictive accuracy of abnormal GMA were calculated in a clinical routine scenario, which used all available GM information (primarily at 3 months or at 1 month, when 3 months were not available). In addition, separate analysis was undertaken for the samples of GMA at 1 and 3 months.

OUTCOMES AND RESULTS

Tips to facilitate GMA implementation are described. In our clinical routine scenario, children with definitely abnormal GM were more likely to have an atypical two-year outcome than children with normal GM (OR 13.2 (95% CI 1.56; 112.5); sensitivity 55.6%, specificity 82.1%). Definitely abnormal GM were associated with reduced MDI (-12.0, 95% CI -23.2; -0.87) and identified all children with cerebral palsy (CP) in the sample of GMA at 3 months only.

CONCLUSIONS AND IMPLICATIONS

GMA can be successfully implemented in a non-academic outpatient setting. In our clinical routine scenario, GMA allowed for adequate prediction of neurodevelopment in infants born preterm, thereby allaying concerns about diagnostic accuracy in non-academic settings.

[Parental Social Status and other determinants of quality of life and behavioral problems: An analysis of German preterm births between 1987-2004]

BACKGROUND

Knowledge of the factors affecting the development of preterm children in Germany is limited. We analysed the prevalence of preterm birth in Germany using the German Health Interview and Examination Survey for Children and Adolescents 2003-2006 and assessed factors associated with quality of life (QOL) and behavioural development in preterm children (< 37 weeks' gestational age).

METHODS

Data were weighted and preterm prevalence was calculated by socioeconomic status (SES) and year of birth for  1,106 preterm children. Using linear regression models, the relationship between sociodemographic, pre- and perinatal, lifestyle, and contextual determinants on the one hand, and the QOL (KINDL® parent questionnaire) and behavioural problems (the total problem behaviour scale, the Strengths and Difficulties Questionnaire [SDQ]) on the other was calculated.

RESULTS

Prevalence of preterm birth (mean 7.5 %) was higher in families with low compared with high SES (8.4 versus 7.0 %). In the final regression models, preterm children with high SES had higher QOL scores (+ 3.3 KINDL points, p = 0.024) compared with children with low SES, and adolescents (aged 14-17 years) had a higher QOL than children aged 7-13 years. All other variables (contextual, pre- and perinatal) were not related to QOL. In contrast, there were many determinants of behavioural development in preterms: the SDQ total score was lower in girls, children with older mothers, those from high SES and those with a high level of physical activity. However, both very low birth weight (< 1,500 g) and birth at > 34 weeks' gestation were associated with a higher SDQ total score.

CONCLUSION

Given its high prevalence, preterm birth is a relevant public health issue in Germany. While SES may be the most important determinant of QOL in preterms, determinants of behavioural problems are the same as those in term children and also encompass perinatal factors.

Early determinants of vagal activity at preschool age - With potential dependence on sex

BACKGROUND

In children, autonomic nervous function is related to various highly prevalent health problems and might therefore represent an early indicator of ill health.

AIMS

We aimed to investigate the role of early-life exposures and physical activity (PA) as potential determinants of autonomic function at preschool age.

STUDY DESIGN AND SUBJECTS

We used an existing longitudinal data set of repeated vagal tone measurements (assessed via heart rate recovery (HRR)) and retrospectively assessed early-life exposures in 1052 children (mean age: 59.4months, 47.5% girls) from 52 preschools in Germany recruited from 2008 to 2010.

OUTCOME MEASURES

HRR 1min after submaximal exercise served as primary outcome. Through multilevel linear regression analysis adjusted for demographic and socioeconomic factors, we assessed the association between repeatedly measured HRR and pregnancy smoking status, breastfeeding and objectively measured PA.

RESULTS

Besides significant regression coefficients for previously described correlates of HRR (sex, age), we could show positive associations of HRR with breastfeeding (six versus zero months: +4.2 beats per minute (BPM), p=0.004) and PA (+1.0BPM for 10min increase of moderate-to-vigorous PA/day, p<0.001). Smoking before and during pregnancy showed no significant association with HRR in the total sample. However, we found interactions between sex and smoking before and during pregnancy as well as between sex and breastfeeding, suggesting significant associations with HRR only in girls.

CONCLUSIONS

Besides PA, early pre- and postnatal exposures seem to have long-lasting effects on children's autonomic function, still recordable at preschool age. Our data suggest that these effects might be sex-dependent.

Lifetime indirect cost of childhood overweight and obesity: A decision analytic model

OBJECTIVE

To estimate the indirect lifetime cost of childhood overweight and obesity for Germany.

METHODS

The lifetime cohort model consisted of two parts: (a) Model I used data from the German Interview and Examination Survey for Children on prevalence of BMI categories during childhood to evaluate BMI trajectories before the age of 18; and (b) Model II estimated lifetime excess indirect cost based on the history of childhood BMI. Indirect costs were defined as the opportunity cost of lost productivity due to mortality and morbidity and were identified through a systematic literature review.

RESULTS

Our analysis showed that the majority of children with overweight and obesity remained in the same BMI category during their adult life, resulting in significant indirect lifetime costs. We estimated that overweight and obesity during childhood resulted in an excess lifetime cost per person of €4,209 (men) and €2,445 (women). For the current prevalent German population, the excess lifetime cost was €145 billion.

CONCLUSIONS

Our study showed that childhood obesity results in significant economic burden on the society. Therefore, cost-effective strategies targeted at reducing the prevalence of obesity during the early years of life can significantly reduce both healthcare and nonhealthcare costs over the lifetime.

Preschools' friendliness toward physical activity: item battery and two scores developed by mixed methods

BACKGROUND

Previous work suggests that many context-level characteristics of preschools are associated with increased physical activity (PA) in children.

PURPOSE

To facilitate assessment of preschools' friendliness toward PA, an item battery as well as comprehensive and short rating scores were developed based on mixed methods with validity and reliability tested.

METHODS

Organizational and contextual characteristics of 24 German preschools were assessed by direct observation and semi-structured interviews (September 2008 to April 2009; analyzed in 2012). Twenty-seven items across seven domains of friendliness toward PA were rated independently by two researchers as being limited (0); adequate (1); or extraordinarily (2) friendly toward PA. Values were summed to a comprehensive rating score value (RS-c). To increase feasibility, a short score (RS-s) was developed using an item subset identified by both item-item correlations and positive association with moderate to vigorous PA. Validity of items and scores was tested by their association with preschoolers' accelerometer-measured PA (n=405) in covariate-adjusted multilevel models. Reliability was tested by inter-rater reliability coefficients.

RESULTS

Nine of 27 items were included in the RS-s. In the multilevel model, four single items and both the RS-c and RS-s were positively associated with children's moderate to vigorous PA (RS-c: β=0.5 minutes, p=0.003, explained variance=9%; RS-s: β=1.3 minutes, p<0.001, variance=23%), but not with light activity or sedentary behavior. Inter-rater reliability was 0.80 (RS-c) and 0.88 (RS-s).

CONCLUSIONS

There is potential value for mixed methods in assessing preschools' friendliness toward PA.

Sweets consumption of preschool children--extent, context, and consumption patterns

OBJECTIVES

Sweets consumption is one of the risk factors of caries, especially among children. The aim of our study was to explore the extent and context of preschoolers' sweets consumption and to identify high-risk groups.

MATERIALS AND METHODS

The baseline cross-sectional data used originated from a nutritional intervention study encompassing 879 parental surveys, which were obtained in 52 kindergartens in Baden-Württemberg-the third largest federal state in Germany-between September and March 2009. Our outcome variable "sweets consumption" was operationalized using food-frequency items and analyzed by testing the influence of sociodemographic, educational, cultural, and family context covariates.

RESULTS

Most preschoolers consumed sweets every day-on average 9.7 ± 6.2 times per week. Most popular were cookies, gummy bears, and chocolate. Sweets consumption did not correlate significantly with sociodemographic factors like age and sex but rather was associated with cultural and contextual factors such as immigrant background, parental education, specific nutritional knowledge levels, and access arrangements in the home.

CONCLUSIONS

The consumption patterns identified are a result of high availability and parental influence (factors such as parents' knowledge levels, interest in, and habits regarding their child's nutrition).

CLINICAL RELEVANCE

Dental practitioners should place more emphasis on gathering information from young patients regarding excessive and frequent consumption of sweets and consequently on trying to educate the children and their parents on oral health risks associated with such consumption. Particular attention is to be paid to children of Turkish and Arabic decent, as they have been shown to consume above-average amounts of sweets.

Sex differences in the variables associated with objectively measured moderate-to-vigorous physical activity in preschoolers

OBJECTIVE

To investigate variables associated with objectively measured moderate-to-vigorous physical activity (MVPA) in German preschool children.

METHODS

Cross-sectional data was collected from 649 three to six year old children (51% boys) in 52 preschools in south Germany between autumn and spring 2008-2009. Sociodemographic, health and socio-cultural variables that could affect children's objectively measured MVPA minutes, averaged over two to four week and weekend days, were tested in bivariate and multivariate linear regression models.

RESULTS

MVPA was significantly associated with the extrinsic variables age (-4.52 min/year of age), health status (5.62 min/category), high TV time (9.22 min/category) and high parental PA (6.59 min/category) among girls. For boys, only the intrinsic variable desire to be active (5.19 min/category) was significantly, positively associated with MVPA. The final models for girls and boys explained approximately 10% and 7% of the variance, respectively, in children's MVPA.

CONCLUSION

We found differences by sex in variables associated with objectively measured MVPA in preschoolers. A focus on extrinsic motivators such as parental PA for girls and intrinsic motivators for boys may be an important consideration when designing interventions and PA programs for this age group.

A participatory parent-focused intervention promoting physical activity in preschools: design of a cluster-randomized trial

Background

With rates of childhood obesity increasing, physical activity (PA) promotion especially in young children has assumed greater importance. Given the limited effectiveness of most interventions to date, new approaches are needed. The General Systems theory suggests that involving parents as intervention targets may be effective in fostering healthier life styles in children. We describe the development of a parent-focused participatory intervention and the procedures used to evaluate its effectiveness in increasing daily PA in preschoolers.

Methods/Design

Thirty-seven South German preschools were identified for this study and agreed to participate. Using a two-armed, controlled cluster-randomized trial design we test a participatory intervention with parents as the primary target group and potential agents of behavioural change. Specifically, the intervention is designed to engage parents in the development, refinement and selection of project ideas to promote PA and in incorporating these ideas into daily routines within the preschool community, consisting of children, teachers and parents. Our study is embedded within an existing state-sponsored programme providing structured gym lessons to preschool children. Thus, child-based PA outcomes from the study arm with the parent-focused intervention and the state-sponsored programme are compared with those from the study arm with the state-sponsored programme alone. The evaluation entails baseline measurements of study outcomes as well as follow-up measurements at 6 and 12 months. Accelerometry measures PA intensity over a period of six days, with the mean over six days used as the primary outcome measure. Secondary outcomes include childrens' BMI, a sum of averaged skin fold thickness measurements across multiple sites, and PA behaviour. Longitudinal multilevel models are used to assess within-subject change and between-group differences in study outcomes, adjusted for covariates at the preschool and individual levels. Teacher qualitative interviews monitor the intervention implementation process.

Discussion

Participatory approaches that actively involve parents have the potential to promote PA in ways that might be better tailored to local needs and more sustainable. Our mixed methods approach to assess the intervention efficacy and implementation employing both quantitative and qualitative measures within a cluster-randomized controlled trial may serve as a framework for evaluating public health interventions in preschool settings.

Trial Registration

clinicaltrials.gov No: NCT00987532

Phototherapy-mediated syndrome of inappropriate secretion of antidiuretic hormone in an in utero selective serotonin reuptake inhibitor-exposed newborn infant

Although selective serotonin reuptake inhibitors (SSRIs) have gained wide acceptance in the off-label treatment of mental disorders in pregnant women, there seems to be an increased risk for serotonergic adverse effects in newborn infants who are exposed to SSRIs during late pregnancy. Hyponatremia as a result of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a relatively common serious side effect of the use of SSRIs in (mostly elderly) adults. Severe hyponatremia as a result of an SIADH is proposed here as part of a neonatal serotonin toxicity syndrome in a newborn infant who was exposed prenatally to an SSRI. The definite reversal to normal serum sodium levels after fluid restriction, the lack of any alternative cause for the SIADH, and the positive temporal relation with a high score on a widely used adverse drug reaction probability scale offer solid support for the hypothesis of a causal relationship between the SIADH and the prenatal sertraline exposure in our neonate. Moreover, accumulative data on the acute enhancement of serotonergic transmission by intense illumination led us to hypothesize that phototherapy used to treat hyperbilirubinemia in the newborn infant could have been the ultimate environmental trigger for this proposed new cause of iatrogenic neonatal SIADH. The speculative role of phototherapy as a physical trigger for this drug-related adverse event should be confirmed in other cases by thorough study of the serotonin metabolism, assay of SSRI levels in cord blood, and serial measurement of plasma levels in exposed neonates. As phototherapy is used frequently in jaundiced neonates and an apparently increasing number of infants are born to mothers who take SSRIs, serotonin toxicity in neonates deserves increased attention.