BACKGROUND: Regulations designed to protect children participating in clinical research often restrict the availability of research data necessary for the development of age-specific therapies and drug dosing. Few data exist on how children experience participation in clinical research, and studies investigating young children undergoing an intensive medical treatment are lacking.
METHODS: Mixed methods with semi-structured interviews and DISCO-RC questionnaires were used to explore young children\'s and their parents\' experiences in clinical research participation during a kidney transplantation trajectory.
RESULTS: Nine children and their parents were interviewed. Children\'s median age at kidney transplantation was 4 years (IQR 4,7); age at interview was 7 years (IQR 6,9). Thematic content analysis of interviews revealed that most children were unaware of having participated in a study. Both children and their parents frequently were unaware whether procedures were standard care or research related. The additional burden attributed to study participation varied from not at all to heavy in combination with intensive medical treatment. Positive experiences included kind healthcare professionals, effective distraction techniques, educational aspects, contributing to science and extra check-ups. Most reported negative experiences were conflicting communication, spending much time in the hospital, missing school and suboptimal planning. Venous puncture was stressful for all children, whereas the discomfort of other procedures varied.
CONCLUSIONS: Pediatric clinical research design should focus on education and fun during research procedures, smart planning, consistent communication, close collaboration between clinical and research team and age appropriate distraction techniques.

Systems thinking has been recognized as valuable to public health policy, research and practice. Commentators and reviews have highlighted that there is still much to be done to embrace its potential. Here, we highlight that much of the discourse about systems thinking in, and for, public health supports the pursuit of a narrow path and is limited with respect to the lineages of Systems that are embraced. We invite readers to see the potential of systems thinking in pursuing a broader path which is motivated by a concern for alleviating health inequalities. This does not replace the narrow path but encompasses it. It prompts different considerations with respect to the nature of the transformation, partnership working and legitimacy. It also invites a different way of engaging with systems thinking and different ways of conceptualizing and managing change. The broad path both requires, and helps enhance, new ways of doing, relating, organizing, knowing and framing which are vital for the future of public health as a global concern.

BACKGROUND: Rural U.S. residents experience a disproportionate burden of diet and physical activity (PA) related chronic disease compared to urban residents, due to resource and economic challenges. Diverse policy approaches for chronic disease prevention have been implemented to address barriers to breastfeeding, healthy eating, and PA. Therefore, the purpose of this paper is to describe policy supports for breastfeeding, healthy eating, and/or PA occurring in rural U.S. areas.
METHODS: A scoping review was conducted March-June 2020 to identify policy, systems, and environment change approaches occurring in the rural U.S. for breastfeeding, healthy eating, and PA. Search procedures were guided by the PRISMA-ScR, Arksey and O\'Malley\'s work (2007), and a science librarian. Medline, PubMed, Web of Science, and Agricola were used to identify peer-reviewed research. ProQuest Dissertations and Theses A&I were used to identify dissertation research. Grey literature searches included Google, Google Scholar, government pages, and public health, federal nutrition assistance program, Cooperative Extension Services, and related webpages. Policy results are reported and inclusion criteria were: (1) breastfeeding, healthy eating, and/or PA focus; (2) about policy factors; (3) specific to U.S. rural populations/places; and (4) English language. Outcomes (study/source design, objective(s), methods/measurement, setting, population characteristics, behavioral focus, policy-specific results) were extracted into a standardized Excel document.
RESULTS: Results include 122 total sources: original research, with some sources referencing multiple behaviors, (n = 74 sources: 8 breastfeeding, 41 healthy eating, 42 PA), grey literature (n = 45 sources: 16 breastfeeding, 15 healthy eating, 27 PA), and graduate research (n = 3 sources: 1 breastfeeding, 2 healthy eating, 1 PA). Breastfeeding policy initiatives included policies or programs at hospitals, increasing access to resources, and improving culture or norms at workplaces. Healthy eating policy initiatives included increasing access to healthy foods, reducing financial burden, implementing programs, food assistance programs, and healthy food prescriptions at healthcare facilities. PA policy initiatives focused on Complete Streets, joint or shared use efforts, Safe Routes to Schools, master plans for greenways, trails, and/or transportation, school health plans, and childcare/school standards.
CONCLUSIONS: Results from this scoping review compile and offer commentary on existing policy solutions to improve breastfeeding, healthy eating, and/or PA in the rural U.S.

Young people who attend intensive alcohol and other drug (AoD) treatment commonly do so more than once. This paper aims to understand precipitators, enablers and barriers to young people\'s re-engagement in programs. Data come from a longitudinal qualitative study involving three waves of interviews with Australian young people recruited while attending intensive AoD programs (n = 38 at wave 1). We found that young people\'s ambitions for what they might achieve with a new stay and capacity to benefit from programs, evolved. Skills learnt in earlier stays or changed life circumstances often helped them achieve better outcomes subsequently. Ongoing contact with an AoD worker was the most important enabler to service re-engagement. Across the span of a year, we saw most young people in our study sample develop a stronger sense of wellbeing and control over substance use. While researchers tend to focus on evaluating outcomes associated with single stays at specific programs, young people think about their trajectories towards managing substance use and their lives as occurring more holistically, supported by engagements with a range of services. We argue that the notion of incremental treatment is useful in depicting the synergistic effects of service engagement over time.

A prospective, qualitative study, of trauma and orthopaedic theatres was undertaken using the CARe QI handbook and the SEIPS framework, with the aim of preventing future Never Events. The study demonstrated a new approach, focussed on understanding \'work as done\' to identify opportunities to improve system resilience, tested, using the Model for Improvement. Undertaken during the Covid-19 pandemic, it demonstrates that such conditions should not be a deterrent to observational studies, but requiring greater time and resource than a standard investigation, the approach may not align with current organisational or regulatory expectations. At the conclusion of this study, the mean time between Never Events in theatres had increased from 46 to 224 days, an achievement that had not previously been possible using the regulatory required, safety I, investigatory approach. These findings should be used to inform future PSIRF and Never Event Frameworks, to ensure effective systems-based analysis and improvement.
The value of applying a prospective approach, incorporating system resilience and quality improvement in response to adverse safety events, was demonstrated, whilst highlighting the time and resource necessary for success. This study supports the recommendation that the use of the prospective systems-based approaches introduced by PSIRF, should be applied to never events.

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Introduction: Kidney Allocation System (KAS) was implemented by United Network for Organ Sharing in 2014 to reduce allocation disparities. Research Questions: Outcomes of highly sensitized patients (calculated panel reactive antibody (cPRA) ≥ 97%) before and after KAS were compared to low-risk recipients (cPRA <10%) in the post-KAS era were examined. The impact on racial disparities was determined. Design: This was a retrospective study of national registry data. Two cohorts of adult candidates waitlisted for deceased donor transplantation during 3-year periods before and after KAS were identified. Results: Highly sensitized patients (N = 1238 and 4687) received a deceased donor kidney transplant between January 1, 2011 and December 31, 2013 and between January 1, 2015 and December, 31, 2017. Racial disparity for highly sensitized patients improved, yet remained significant (P < 0.001), with Black patients comprising 40% and 41% of the highly sensitized candidates and 28% and 34% of the recipients pre- and post-KAS. While posttransplant death-censored graft failure for highly sensitized recipients was similar overall, post-KAS was associated with improved graft survival in the first year after transplant (HR 0.56, 95% CI 0.40-0.78). When compared to contemporaneous lowrisk recipients, both death-censored and all-cause graft failure were similar for highly sensitized recipients and was associated with increased risk for death-censored graft failure beyond the first year (HR 1.39, 95% CI 1.11-1.73). Conclusion: The allocation system led to an increase in transplantation in highly sensitized candidates without compromising outcomes. Although KAS has led to more balanced transplant rates between highly sensitized Black and White patients, racial inequalities persist.

In the autism field, there is increasing interest in translating evidence-based interventions (EBIs) into systems that serve young autistic children and their families. Public Early Intervention systems have been a focal point of research-based implementation efforts given that these systems are federally mandated to provide services to children birth to three years of age with developmental delays under Part C of the Individuals with Disabilities Education Act. Although a growing number of research studies are now training Early Intervention providers to deliver autism EBIs, this work has been conducted on a relatively small scale and has only just begun to consider the alignment of these models with Early Intervention systems and whether sufficient infrastructure exists to scale up these training efforts and to sustain their public health impact. This commentary aims to address this gap by reviewing factors that have been found to uniformly impact the scale-up of EBIs across diverse public systems (Fagan 20, 1147-1168, 2019), and to extend this framework to the implementation of EBIs within public Early Intervention systems. These factors include developer and funder capacity, the public\'s awareness of and support for EBIs, the system\'s leadership support for EBI use, the capacity for community engagement in implementation efforts, the availability of a skilled workforce capable of delivering EBIs, and the capacity for data monitoring and quality improvement. This commentary discusses how these factors may specifically impact the scale-up of autism EBIs within EI systems to support toddlers and young, autistic children, and implications for autism researchers.

BACKGROUND: Despite the existence of physical activity policies across many countries, insufficient physical activity remains a major global public health problem. Physical inactivity is an emergent feature of complex systems; it results from a wide range of factors at multiple levels that interact to influence behavior. Traditional approaches to public policy often fail within complex systems, largely due to unpredictability in how the system will respond. Adaptive policies, which are designed to allow for uncertainty about future system behavior and to change over time, may offer a promising solution. In this paper, we introduce the concept of adaptive policies and illustrate how this innovative approach to policy making may be beneficial for reducing physical inactivity.
METHODS: Drawing on existing literature and guiding principles for policy making, we provide 3 examples to illustrate how the concept of adaptive policies can be applied to address physical inactivity.
CONCLUSIONS: The examples illustrate how changes to the way policies and interventions are developed, implemented, and evaluated could help to overcome some of the limitations in existing practices. A key challenge will be engaging policymakers to take a broader perspective of the physical activity system, develop policies that are designed to be adaptable across a range of different future scenarios, and embrace uncertainty and long-term adaptability.
CONCLUSIONS: Adaptive policies may support decision makers globally to achieve the widespread and sustained changes necessary to increase population levels of physical activity.

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