Lindsay A. Thompson

Background: In the United States, only 58% of teens receive the recommended 2 doses of the human papillomavirus vaccine by 15 years of age. Overcoming vaccine hesitancy often requires effective communication between clinicians and parents to address specific concerns. To support this, we developed ProtectMe4, a multilevel, theory-informed web-based intervention designed to address parents’ vaccine-related questions and assist clinicians in discussing vaccine concerns for 4 adolescent vaccines. Objective: This study aims to evaluate the usability of ProtectMe4 in routine care settings across 3 pediatric primary care clinics. Specifically, the study aims to (1) observe the proposed workflow in practice, (2) identify usability issues experienced by parents and clinicians, and (3) assess the perceptions of both parents and clinicians regarding the app’s usability. Methods: On designated days in 2020 and 2021, the study team recruited parents of 11- to 12-year-old patients attending appointments with participating clinicians. We conducted think-aloud assessments during routine care visits and administered a usability survey after participants used the app. For parents, we simultaneously video-recorded the app screens and audio-recorded their commentary. For clinicians, observational notes were taken regarding their actions and comments. Timings recorded within the app provided data on the length of use. We reviewed the recordings and notes to compile a list of identified issues and calculated the frequencies of survey responses. Results: Out of 12 parents invited to use the app, 9 (75%) participated. Two parents who were invited outside of the planned workflow, after seeing the clinician, refused to participate. For the parents whose child’s vaccination record was identified by the app, the median time spent using the app was 9 (range 6-28) minutes. Think-aloud assessment results for parents were categorized into 2 themes: (1) troubleshooting vaccine record identification and (2) clarifying the app content and purpose. Among the 8 parents who completed the survey, at least 75% (6/8) agreed with each acceptability measure related to user satisfaction, perceived usefulness, and acceptance. These parents’ children were patients of 4 of the 7 participating clinicians. Consistent with the planned workflow, clinicians viewed the app before seeing the patient in 4 of 9 (44%) instances. The median time spent on the app per patient was 95 (range 5-240) seconds. Think-aloud assessment results for clinicians were grouped into 2 themes: (1) trust of app vaccine results and (2) clarifying the app content. On the survey, clinicians were unanimously positive about the app, with an average System Usability Scale score of 87.5 (SE 2.5). Conclusions: This mixed methods evaluation demonstrated that ProtectMe4 was usable and acceptable to both parents and clinicians in real-world pediatric primary care. Improved coordination among clinic staff is needed to ensure the app is consistently offered to patients and reviewed by clinicians before seeing the patient.

BACKGROUND In the United States, only 58% of teens receive the recommended 2 doses of the human papillomavirus vaccine by 15 years of age. Overcoming vaccine hesitancy often requires effective communication between clinicians and parents to address specific concerns. To support this, we developed ProtectMe4, a multilevel, theory-informed web-based intervention designed to address parents’ vaccine-related questions and assist clinicians in discussing vaccine concerns for 4 adolescent vaccines. OBJECTIVE This study aims to evaluate the usability of ProtectMe4 in routine care settings across 3 pediatric primary care clinics. Specifically, the study aims to (1) observe the proposed workflow in practice, (2) identify usability issues experienced by parents and clinicians, and (3) assess the perceptions of both parents and clinicians regarding the app’s usability. METHODS On designated days in 2020 and 2021, the study team recruited parents of 11- to 12-year-old patients attending appointments with participating clinicians. We conducted think-aloud assessments during routine care visits and administered a usability survey after participants used the app. For parents, we simultaneously video-recorded the app screens and audio-recorded their commentary. For clinicians, observational notes were taken regarding their actions and comments. Timings recorded within the app provided data on the length of use. We reviewed the recordings and notes to compile a list of identified issues and calculated the frequencies of survey responses. RESULTS Out of 12 parents invited to use the app, 9 (75%) participated. Two parents who were invited outside of the planned workflow, after seeing the clinician, refused to participate. For the parents whose child’s vaccination record was identified by the app, the median time spent using the app was 9 (range 6-28) minutes. Think-aloud assessment results for parents were categorized into 2 themes: (1) troubleshooting vaccine record identification and (2) clarifying the app content and purpose. Among the 8 parents who completed the survey, at least 75% (6/8) agreed with each acceptability measure related to user satisfaction, perceived usefulness, and acceptance. These parents’ children were patients of 4 of the 7 participating clinicians. Consistent with the planned workflow, clinicians viewed the app before seeing the patient in 4 of 9 (44%) instances. The median time spent on the app per patient was 95 (range 5-240) seconds. Think-aloud assessment results for clinicians were grouped into 2 themes: (1) trust of app vaccine results and (2) clarifying the app content. On the survey, clinicians were unanimously positive about the app, with an average System Usability Scale score of 87.5 (SE 2.5). CONCLUSIONS This mixed methods evaluation demonstrated that ProtectMe4 was usable and acceptable to both parents and clinicians in real-world pediatric primary care. Improved coordination among clinic staff is needed to ensure the app is consistently offered to patients and reviewed by clinicians before seeing the patient.

Epidemiological data demonstrate that bovine whole milk is often substituted for human milk during the first 12 months of life and may be associated with adverse infant outcomes. The objective of this study is to interrogate the human and bovine milk metabolome at 2 weeks of life to identify unique metabolites that may impact infant health outcomes. Human milk (n = 10) was collected at 2 weeks postpartum from normal-weight mothers (pre-pregnant BMI < 25 kg/m²) that vaginally delivered term infants and were exclusively breastfeeding their infant for at least 2 months. Similarly, bovine milk (n = 10) was collected 2 weeks postpartum from normal-weight primiparous Holstein dairy cows. Untargeted data were acquired on all milk samples using high-resolution liquid chromatography–high-resolution tandem mass spectrometry (HR LC-MS/MS). MS data pre-processing from feature calling to metabolite annotation was performed using MS-DIAL and MS-FLO. Our results revealed that more than 80% of the milk metabolome is shared between human and bovine milk samples during early lactation. Unbiased analysis of identified metabolites revealed that nearly 80% of milk metabolites may contribute to microbial metabolism and microbe–host interactions. Collectively, these results highlight untargeted metabolomics as a potential strategy to identify unique and shared metabolites in bovine and human milk that may relate to and impact infant health outcomes.

In Reply We appreciate the comments from Brooks et al, who offer perspectives on youth weight lifting in response to our article “Physical Activity in Children.”¹ As our article noted, children should engage in many types of activities, which importantly includes weight-bearing exercise. We appreciate these authors’ insights on the specifics of weight lifting in children, where they note that “well-designed weight lifting programs have no apparent negative effect on linear growth,” and encourage consensus in this area. We could not agree more. Identify all potential conflicts of interest that might be relevant to your comment. Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. Err on the side of full disclosure. If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response. Not all submitted comments are published. Please see our commenting policy for details.

Low HPV vaccinations rates lead to missed opportunities to prevent cancer. Specifically, some parents (12–76%) report never receiving a recommendation for their child to receive the vaccine. Current models for talking about HPV vaccination fall short in that they focus primarily on how to introduce the vaccine with limited guidance on how to follow through with the conversation, particularly with those parents who may be hesitant. We developed the C-LEAR approach, an easy to remember, evidence-informed mnemonic to guide clinicians through the process of introducing and discussing the HPV vaccine with parents. We pilot tested this approach with a total of 20 pediatric clinicians (n = 13 residents; n = 7 attendings) in 60-min Zoom workshops that included a short didactic session, a demonstration of skills, and a small group, facilitator-led role play session. On an immediate post-training survey, all participants stated that the training was helpful and easy to understand. Ninety-four percent responded that they would implement what they had learned in their clinic. Participants reported appreciation for the small group sessions. While not specifically asked or required to incorporate the material into their practice, 1 year following the training, 8/9 (88%) participants reported using the C-LEAR approach in their clinics “most” or “all of the time.” We are further testing this model through teaching our workshop in a large, randomized trial across the state of Florida.

Objective The American Board of Pediatrics’ (ABP) maintenance of certification (MOC) programme seeks to continue educating paediatricians throughout their careers by encouraging lifelong learning and continued improvement. The programme includes four parts, each centring on a different aspect of medical practice. Part 4 MOC centres on quality improvement (QI). Surveys by the ABP suggest that paediatricians are dissatisfied with aspects of part 4, but their reasons are unclear. This study sought to explore factors contributing to dissatisfaction with part 4 by focusing on performance improvement modules (PIMs), a popular means of achieving part 4 credit. Methods The study used cross-sectional purposive sampling drawing from US physicians working in a range of practice settings: private outpatient, hospital, academic and low-income clinics. The sampling frame was divided by practice characteristics and satisfaction level, derived from a five-point Likert item asking about physician satisfaction regarding a recent PIM. In-depth interviews were conducted with 21 physicians, and the interview data were coded, categorised into themes and analysed using a framework analysis approach. Results Paediatricians expressed nuanced views of PIMs and remain globally dissatisfied with part 4, although reasons for dissatisfaction varied. Concerns with PIMs included: (1) excessive time and effort; (2) limited improvement and (3) lack of clinically relevant topics. While most agreed that QI is important, participants felt persistently dissatisfied with the mechanics of doing PIMs, especially when QI tasks fell outside of their typical work regimen. Conclusions Paediatricians agreed that part 4, PIMs, and QI efforts in general still lack clinical relevance and need to be more easily incorporated into practice workflow. Clinicians specifically felt that PIMs must be directly integrated with physicians’ practice settings in terms of topic, data quality and metrics, and must address practice differences in time and monetary resources for completing large or complex projects.

Objective Many of the medical risk factors for adverse birth outcomes (e.g., preeclampsia) are regularly monitored in prenatal care. However, many of the psychosocial risk factors associated with adverse birth outcomes (e.g., maternal stress, anxiety, depression, intimate partner violence) are not regularly addressed during routine prenatal care. Comprehensive prenatal screening for psychosocial risk factors for adverse birth outcomes can improve maternal and neonatal outcomes. In this study, we examine an existing tool for opportunities to streamline and improve screening. Methods We reviewed medical records for 528 mother-infant dyads, recording maternal responses to a 21-item prenatal risk screening tool, and gestational age/birth weight of infants. Multiple approaches to scoring were used to predict likelihood of adverse birth outcome. Results Women who answered yes to any of the top four interrelated items were 3.32 times more likely to have an adverse birth outcome. Sensitivity and specificity were 68% and 65%, respectively. Conclusion for Practice We identified a short surveillance tool to identify women who are at highest risk and require more in-depth screening, and to rule out women who are at very low risk of an adverse birth outcome.