A formative evaluation of the American Diabetes Association's Choosing Health and Sensible Exercise childhood obesity intervention

Background. The increasing prevalence of overweight among youth in the United States, and the parallel rise in related medical comorbidities has led to a growing need for efficient weight-management interventions. Purpose. The aim of this study was to evaluate the effects of the Choosing Health and Sensible Exercise (C.H.A.S.E.) childhood obesity prevention program on Body Mass Index (BMI), physical activity and dietary behaviors. Methods. This study utilized de-identified data collected during the fall 2006 session of the C.H.A.S.E. program. A total of 65 students at Woodview Elementary School and Deepwater Elementary School participated in this intervention. The C.H.A.S.E. program is a 10-week obesity prevention program that focuses on nutrition and physical activity education. Collection of height and weight data, and a health behavior survey was conducted during the first and last week of the intervention. Paired t-tests were used to determine statistically significant differences between pre- and post-intervention measurements. One-way analysis of variance was used to adjust for potential confounders, such as gender, age, BMI category ("normal weight", "at risk overweight", or "overweight"), and self-reported weight loss goals. Data were analyzed using STATA, v. 9.2. Results. A significant decrease in mean BMI (p< 0.05) was found after the 10-week intervention. While the results were statistically significant for the group as a whole, changes in BMI were not significant when stratified by age, sex, or ethnicity. The mean overall scores for the behavior survey did not change significantly pre- and post-intervention; however, significant differences were found in the dietary intention scale, indicating that students were more likely to intend to make healthier food choices (p<0.05). No statistically significant decreases in BMI were found when stratified for baseline BMI-for-age percentiles or baseline weight loss efforts (p>0.05). Conclusion. The results of this evaluation provide information that will be useful in planning and implementing an effective childhood obesity intervention in the future. Changes in the self-reported dietary intentions and BMI show that the C.H.A.S.E. program is capable of modifying food choice selection and decreasing BMI. Results from the behavior questionnaire indicate that students in the intervention program were making changes in a positive direction. Future implementation of the C.H.A.S.E. program, as well as other childhood obesity interventions, may want to consider incorporating additional strategies to increase knowledge and other behavioral constructs associated with decreased BMI. In addition, obesity prevention programs may want to increase parental involvement and increase the dose or intensity of the intervention. ^

Hazardous air pollutants and childhood lymphohematopoietic cancer in Southeast Texas, 1995--2004

Southeast Texas, including Houston, has a large presence of industrial facilities and has been documented to have poorer air quality and significantly higher cancer rates than the remainder of Texas. Given citizens’ concerns in this 4th largest city in the U.S., Mayor Bill White recently partnered with the UT School of Public Health to determine methods to evaluate the health risks of hazardous air pollutants (HAPs). Sexton et al. (2007) published a report that strongly encouraged analytic studies linking these pollutants with health outcomes. In response, we set out to complete the following aims: 1. determine the optimal exposure assessment strategy to assess the association between childhood cancer rates and increased ambient levels of benzene and 1,3-butadiene (in an ecologic setting) and 2. evaluate whether census tracts with the highest levels of benzene or 1,3-butadiene have higher incidence of childhood lymphohematopoietic cancer compared with census tracts with the lowest levels of benzene or 1,3-butadiene, using Poisson regression. The first aim was achieved by evaluating the usefulness of four data sources: geographic information systems (GIS) to identify proximity to point sources of industrial air pollution, industrial emission data from the U.S. EPA’s Toxic Release Inventory (TRI), routine monitoring data from the U.S. EPA Air Quality System (AQS) from 1999-2000 and modeled ambient air levels from the U.S. EPA’s 1999 National Air Toxic Assessment Project (NATA) ASPEN model. Further, once these four data sources were evaluated, we narrowed them down to two: the routine monitoring data from the AQS for the years 1998-2000 and the 1999 U.S. EPA NATA ASPEN modeled data. We applied kriging (spatial interpolation) methodology to the monitoring data and compared the kriged values to the ASPEN modeled data. Our results indicated poor agreement between the two methods. Relative to the U.S. EPA ASPEN modeled estimates, relying on kriging to classify census tracts into exposure groups would have caused a great deal of misclassification. To address the second aim, we additionally obtained childhood lymphohematopoietic cancer data for 1995-2004 from the Texas Cancer Registry. The U.S. EPA ASPEN modeled data were used to estimate ambient levels of benzene and 1,3-butadiene in separate Poisson regression analyses. All data were analyzed at the census tract level. We found that census tracts with the highest benzene levels had elevated rates of all leukemia (rate ratio (RR) = 1.37; 95% confidence interval (CI), 1.05-1.78). Among census tracts with the highest 1,3-butadiene levels, we observed RRs of 1.40 (95% CI, 1.07-1.81) for all leukemia. We detected no associations between benzene or 1,3-butadiene levels and childhood lymphoma incidence. This study is the first to examine this association in Harris and surrounding counties in Texas and is among the first to correlate monitored levels of HAPs with childhood lymphohematopoietic cancer incidence, evaluating several analytic methods in an effort to determine the most appropriate approach to test this association. Despite recognized weakness of ecologic analyses, our analysis suggests an association between childhood leukemia and hazardous air pollution.^

Associations between vaccination and childhood cancers in Texas counties

Background. In Dr. Mel Greaves "delayed-infection hypothesis," postponed exposure to common infections increases the likelihood of childhood cancer. Hygienic advancements in developed countries have reduced children's exposure to pathogens and children encounter common infectious agents at an older age with an immune system unable to deal with the foreign antigens. Vaccinations may be considered to be simulated infections as they prompt an antigenic response by the immune system. Vaccinations may regulate the risk of childhood cancer by modulating the immune system. The aim of the study was to determine if children born in Texas counties with higher levels of vaccination coverage were at a reduced risk for childhood cancer.^ Methods. We conducted a case-control study to examine the risk of childhood cancers, specifically leukemia, brain tumors, and non-Hodgkin lymphoma, in relation to vaccination rates in Texas counties. We utilized a multilevel mixed-effects regression model of the individual data from the Texas Cancer Registry (TCR) with group-level exposure data (i.e., the county- and public health region-level vaccination rates).^ Results. Utilizing county-level vaccination rates and controlling for child's sex, birth year, ethnicity, birth weight, and mother's age at child's birth the hepatitis B vaccine revealed negative associations with developing all cancer types (OR = 0.81, 95% CI: 0.67–0.98) and acute lymphoblastic leukemia (ALL) (OR = 0.63, 95% CI: 0.46–0.88). The decreased risk for ALL was also evident for the inactivated polio vaccine (IPV) (OR = 0.67, 95% CI: 0.49–0.92) and 4-3-1-3-3 vaccination series (OR = 0.62, 95% CI: 0.44-0.87). Using public health region vaccine coverage levels, an inverse association between the Haemophilus influenzae type b (Hib) vaccine and ALL (OR: 0.58; 95% CI: 0.42–0.82) was present. Conversely, the measles, mumps, and rubella (MMR) vaccine resulted in a positive association with developing non-Hodgkin lymphoma (OR = 2.81, 95% CI: 1.27–6.22). ^

Evaluation of association between childhood obesity and depression: A systematic literature review

Obesity has become a major public health concern throughout the world. Both developing as well as developed countries have been facing the consequences of obesity. [1, 2] According to World Health Organization, worldwide prevalence of overweight among adults was 1.6 billion and that of obesity was 400 million by the end of year 2005. At the same time, around 20 million children of less than 5 years of age were overweight worldwide. [3] ^ From amongst the obese children, around 15% of children manifest symptoms of depression before 18 years of age as compared to non-obese children of the same age group. Approximately 3-5% of these obese individuals develop major depressive disorders (MDD). [4, 5] The incidence of depression increases markedly as the child reaches puberty. The risk of persistent depression in childhood as well as in adulthood is two to four times higher if the child is obese as compared to those depressed adult individuals who are not obese in their childhood. [6, 7] ^ This paper will review the scientific literature concerning the association between childhood obesity and depression. ^

A summative evaluation of a HIV/AIDS Early Childhood Care, Education and Development Teacher Training Workshop in Mongu, Zambia

Objective. To conduct a summative evaluation of an Early Childhood Care, Education and Development (ECCED) Teacher Training Workshop in Mongu, Zambia by assessing changes in knowledge, attitudes and intent to use the information. ^ Study design. A matched cohort survey design was used with additional qualitative data collected by structured observation of workshop sessions, daily facilitator and participant debriefs and participant interviews. ^ Results. Matching pre and post tests were completed by 27 individuals in addition to daily debriefs, structured workshop observation and participant interviews with 22% of the group. The participant population was predominantly female individuals aged 15-44 years old that had completed high school and additional post-secondary training, been teaching children aged 0 – 8 years for 2-5 years in the Western Province and received other HIV/AIDS and ECCED education. Pre-tests indicated a strong understanding of ECCED principles and misconceptions regarding HIV transmission, prevention and the disease's impact on early childhood development. The workshop was found to significantly increase the participants' knowledge of topics covered by the curriculum (paired t-test, N=27, p = 0.004, 95% CI 1.8, 8.6). Participants began with a more limited understanding of HIV/AIDS than ECCED, but the mean gain was much greater at 7.4 +/- 12.3 points. Significantly more participants believed at post-test that HIV/AIDS education should increase for future educators. The 77.8% of participants that increased their knowledge scores at post-test expressed significantly less fear of having a child with HIV/AIDS in the classroom (Independent Samples t-test, N= 27, p = 0.011). Overall participant fear decreased 15.5%. 92.6% and 88.9% of participants planned at post-test to respectively use and share the taught information in their daily professional lives and reported on innovative strategies to communicate with the community. ^ Conclusions. Teacher training workshops can significantly increase HIV/AIDS awareness and promote positive attitudes in educators working with children affected by HIV/AIDS. Using participant suggested teaching techniques such as poems and songs and translating the materials to the local language could assist future facilitators to both culturally and professionally relate to the workshop audience as well as increase participant capacity to share the information with the local community. ^

Capitalizing on success against childhood HIV/AIDS in Botswana: Towards a comprehensive healthcare policy for pediatric oncology in Botswana

Pediatric HIV/AIDS in sub-Saharan Africa has been a major public health crisis with an estimated 3.5 million children infected. Baylor International Pediatric AIDS Initiative (BIPAI) has created a network of centers providing care and treatment for these children in several countries. In Botswana, where the first BIPAI center in Africa was opened, childhood mortality from HIV/AIDS is now less than 1%. Botswana is a middle-income country that previously held the highest HIV prevalence rate in the world. Efforts against HIV/AIDS have resulted in the building of a strong medical infrastructure with clear success against pediatric HIV/AIDS. The WHO predicts the next global health crisis will be cancer. Given the increased incidence of cancer in the setting of HIV/AIDS, Botswana has already implemented strategies to combat HIV-related malignancies in adults, but efforts in pediatrics have been lagging. This policy paper describes the importance of building on success against pediatric HIV/AIDS and extending this success to pediatric cancer in general. Specifically, it outlines a comprehensive pediatric cancer policy for the education and training of health professionals, the development of a pediatric cancer program, a pediatric cancer registry, public awareness efforts, and an appropriate, country specific pediatric cancer research agenda.^

Rules to limit snacking in front of the TV and childhood BMI status: Findings from the "Fun Families Study"

Childhood obesity is increasing at epidemic rates, and thus there is a need to target appropriate childhood behaviors that contribute to obesity. Many factors contribute to childhood weight status. The aim of this study was to look at relationships between parental rules to limit snacking while watching television and childhood weight status. The study looked at the presence of the behavior of snacking while watching television yesterday, congruence between child- and parent-reported perception of the presence of rules to limit snacking while watching television, and parent-reported frequency of children following rules to limit snacking while watching television. The outcomes were examined in a multi-ethnic population of children ages 6 to 9 years in Southeast Texas.^ This study was a cross-sectional secondary data analysis of the pilot program, Fun Families. This study examined baseline data from 202 parent-child dyads, which included both the control ( N= 101) and intervention groups (N= 101). Data were gathered using validated questions that were administered to 6-9 year old children and their primary caregiver (referred to as parent in the rest of the discussion) in Southeast Texas, between 2006 and 2008. The main study outcome was childhood weight status based on CDC BMI-for-age categories. The independent variables are (1) the presence of parental rules to limit snacking while watching television, (2) the congruence between child and parent about the presence of rules to limit snacking while watching television, and (3) the parent-reported frequency of the child following the rules to limit snacking while watching television. Chi-Square analyses were used to determine if weight status was different for (1) children who reported rules to limit snacking yesterday, (2) children who reported snacking, (3) children whose parents reported rules were present, and (4) those who had rule congruence with the parents not. Chi-Square analyses also examined if there was a difference in the presence of snacking behavior for children who reported rules, for children whose parents reported rules, and for those children who had congruence about rules. Linear regressions were used to determine if any of the studied variables predicted increased weight status or reported snacking while watching television yesterday.^ This study found that child-reported snacking yesterday was significantly different for children who reported rules (4.12, p= 0.04). Child-reported rules was significantly associated with (p= -0.14, α= 0.04) and predicted child-reported snacking yesterday (R 2 0.021, p= 0.04, t= -2.04, 95% CI -0.31, -0.01). There was statistical significant incongruence between child and parent perception about the presence of rules to limit snacking yesterday (15.06, p= 0.00). For this population, parent education level was significantly associated with child-reported rules (r= -0.16, p= 0.02), child-reported snacking yesterday (r= -0.15, p= 0.04), and parent-reported frequency of child following rules to limit snacking (r= 0.29, p= -0.01). Parent-reported speaking another language besides English at home was significantly associated with parent-reported rules (r= 0.17, p= 0.02).^ Although the studied variables did not show any significant associations or predictors for childhood weight status, the significant discord between parent and child perception about the presence of rules provides valuable information to future interventions that aim to reduce childhood weight status. Including the creation and enforcement of parental rules in interventions to reduce childhood weight status will be beneficial for future studies.^

Genetic epidemiology of childhood brain tumors

A rare familial cancer syndrome involving childhood brain tumors (CBT), breast cancer, sarcomas and an array of other tumors has been described (Li and Fraumeni 1969, 1975, 1982, 1987). A survey of CBT identified through the Connnecticut Tumor Registry in 1984 revealed a high frequency of CBT, leukemia and other childhood cancer in siblings of CBT patients (Farwell and Flannery, 1984). Other syndromes such as neurofibromatosis and nevoid basal cell carcinoma syndrome have also been associated with CBT; however, no systematic family studies have been conducted to determine the extent to which cancer aggregates in family members of CBT patients. This family study was designed to determine the frequency of cancer aggregation overall or at specific sites, to determine the frequency of known or potentially hereditary syndromes in families of CBT patients, and to determine a genetic model to characterize familial cancer syndromes and to identify specific kindreds to which such a model(s) might apply. This study includes 244 confirmed CBT patients referred to the University of Texas M. D. Anderson Cancer Center between the years 1944 and 1983, diagnosed under the age of 15 years and resident in the U.S. or Canada. Family histories were obtained on the proband's first (parents, siblings and offspring) and second degree (proband's aunts, uncles and grandparents) relatives following sequential sampling scheme rules. To determine if cancer aggregates in families, we compared the cancer experience in the population to that expected in the general population using Connecticut Tumor Registry calendar year, age, race and sex-specific rates. The standardized incidence ratio (SIR) for cancer overall was 0.91 (41 observed (O) and 44.94 expected (E); 95% Confidence Interval (CI) = 0.65-1.24). We observed a significant excess of colon cancer among the proband's first degree relatives (O/E = 5/1.64; 95% CI = 1.01-7.65), in particular those under age 45 year. Segregation analysis showed evidence for multifactorial inheritance in the small percentage (N = 5) of the families. ^

Low birthweight and the risk of developing subsequent high blood pressure and/or dyslipidemia in childhood

The association between birthweight and blood pressure (BP), and birthweight and serum lipid concentrations at age 7 through 11 years was examined in 1446 black and white children. The prevalence ratio (with 95% confidence interval) for being in the race-, sex- and age-specific upper decile of diastolic BP in children born with low birthweight (LBW, $<$2500 grams) versus children with birthweight $\geq$2500 grams was for black boys, 2.66 (1.24-5.70). In the other race-sex groups for diastolic BP, and in all race-sex groups for systolic BP this ratio did not differ from one. Among white boys with LBW, but not in the other race-sex groups, higher than expected percentages of subjects were in the highest decile group of triglyceride concentrations (0.01 $<$ p $<$ 0.05). The prevalence ratio was 2.42 (1.19-4.91). When prematures were excluded only more than expected white girls with LBW were in the highest decile group of triglyceride concentrations. The prevalence ratio was 3.23 (1.16-9.00). Prevalence ratios for triglyceride concentrations in black boys and girls, and for LDL/HDL-C ratio, cholesterol and VLDL-C concentrations in all race-sex groups were not different from one in analyses including and in those excluding prematures. Mean triglyceride concentrations stratified by tertiles of Quetelet Index, race and sex showed a strongly positive association between triglyceride concentrations and Quetelet Index, and in the upper tertile of the Quetelet Index an association between LBW and raised triglyceride concentrations. Multiple linear regression analyses showed that after adjusting for sex, race and age present Quetelet Index (p $<$ 0.001) is a much stronger predictor of systolic and diastolic BP, and also of LDL-C/HDL-C ratio and triglyceride concentrations in this age group than birthweight (p $>$ 0.05). Thus, an association between LBW and subsequent risk for elevated BP was confirmed for diastolic BP in black boys, but not for the other race-sex groups, and not for systolic BP in any group. This is the first study finding an association between LBW and elevated triglyceride concentrations in boys (white and black) and girls (white). A follow-up study to assess whether the findings can be confirmed at adult age is recommended. ^

MEETING THE NEEDS OF HANDICAPPED CHILDREN: A STUDY OF EDUCATIONAL AND HEALTH CARE SERVICES PROVIDED TO PRE-KINDERGARTEN CHILDREN IN THE HOUSTON INDEPENDENT SCHOOL DISTRICT EARLY CHILDHOOD PROGRAM FOR THE HANDICAPPED (PARENT SATISFACTION, FUNCTIONAL STATUS, PSYCHOSOCIAL DEVELOPMENT)

The Education for All Handicapped Children Act of 1975, P.L. 94-142, created a new challenge for the nation's public school systems. During 1982-1983, a national study, called the "Collaborative Study of Children with Special Needs", was conducted in 5 metropolitan school districts to evaluate the effectiveness of education and health care services of children in kindergarten to 6th grade being provided under P.L. 94-142 programs. This dissertation (the Substudy) was undertaken to augment the findings of the Collaborative Study. The purpose of this study was to develop a database to provide descriptive information on the demographic, service and health characteristics of a small group of 3 and 4 year old handicapped children served by the Houston Independent School District (HISD) during 1982-1983.^ The study involved a stratified sample of 105 three and four year old children divided into 3 groups according to type of handicapping condition.^ The results of the study gave a clearer picture of the demographic characteristics of these Pre-K children. Specifically, sex ratio was approximately one, lower than the national norm. Family and socioeconomic characteristics were assessed.^ The study used an independence/dependence index composed of 11 items on the parent questionnaire to assess the level of functional independence of each child. An association was found between index scores and parent-reported effects of the child on family activity. Parents who said that their child's condition had affected the family's job situation, housing accomodations, vacation plans, marriage, choice of friends and social activities were also more likely to report less independence in the child. In addition, many of the Substudy children had extensive care-taking needs reflected in specific components of the index such as dressing, feeding, toileting or moving about the house.^ In general the results of the Pre-K Substudy indicate that at the early childhood level, the HISD special education program is functioning well in most areas and that parents are very satisfied with the program. (Abstract shortened with permission of author.)^

Are school nurses effective in the fight against childhood obesity?

Background. With childhood obesity on the rise in the United States, school nurses are faced with the task of preventing, identifying and treating obese children in their schools. This study reviews current literature and examines the effectiveness of the school nurse regarding obesity prevention and treatment services and the barriers they face.^ Methods. Ovid, Ebsco, Google Scholar and other professional websites were searched for school-based obesity interventions that included school nurses and that took place in the United States between 1996 and present day. This resulted in 8 studies.^ Results. Of the 8 studies identified, the majority were conducted in the Midwest, all of the studies were cross-sectional in design or qualitative in nature and only half of these studies were based off theoretical design. The most common barriers school nurses face include: lack of time, lack of support from both the school and parents, lack of confidence in counseling students and their parents and lack of specific guidelines for their role. ^ Conclusions. This study further reflects the need for more research using experimental research designs to evaluate nurse-driven interventions and nurse-related policies for childhood obesity prevention and treatment, the need to create specific guidelines for school nurses, the need for further education for nurses relating to counseling, and the need for more support from the school and community for school-based obesity prevention. ^

Teacher support and encouragement in the classroom and its impact on childhood obesity

Objectives. Obesity is a growing problem in the United States among children. Great efforts are being made to target this problem, both at home and at school. While parents and peers have proven an effective means of distributing information, the well of the influence of teacher encouragement of health behaviors remains untapped. The purpose of this study is to assess the association of teacher encouragement with diet and physical activity behaviors and obesity in a sample of eighth grade students in central Texas. ^ Methods. In the spring of 2011, the Coordinated Approach to Child Health (CATCH) study distributed teacher surveys to each of the teachers in the schools on the grant. In addition to questions concerning the implementation of CATCH, this survey employed social support questions to gauge the prevalence of teacher encouragement of health behaviors in the classroom. During the same time frame, eighth graders in these same schools completed student surveys which assessed dietary and physical activity knowledge and behaviors and demographics and participated in objective measures of student height and weight. A cross-sectional secondary data analysis was conducted in order to compare self-reported teacher encouragement to student behaviors and several student obesity measures on a by school basis. ^ Results. 1150 teachers and 2582 students from 29 of the 30 measurement schools returned completed surveys. No statistically significant relationship was found between the six teacher encouragement measures and their corresponding student reported health behaviors, nor was one found the mean support per school and child percent overweight. A menial positive relationship was found between the mean support per school and child BMI z-scores, BMI, and percent obese (p = 0.035, 0.003 and 0.003, respectively); however, these relationships were not in the predicted direction. ^ Conclusion. While the findings of this investigation show primarily null results, motivating questions as to the impact to teacher encouragement on middle school student's health remain. It is possible that in order to draw more effective conclusions, more comprehensive studies are warranted which specifically target these relationships.^

Computerizing Social-Emotional Assessment for School Readiness: First Steps toward an Assessment Battery for Early Childhood Settings

The transition into formal schooling is a crucial foundation that can set children on a cycle of success or failure in both academic and social domains. A child’s abilities to express healthy emotions, understand emotions of self and others, regulate emotion, attention, and behavior, make good decisions regarding social problems, and engage in a range of prosocial behaviors, all work together to promote a successful school experience. However, many children have deficits in these skills by school entry, and educators lack the requisite tools to identify, track and assess skills these children need to learn. Thus, because social-emotional learning (SEL) is so crucial, assessment tools to pinpoint children’s skills and progress are vitally necessary. Previous work by the authors and other researchers has led to the development of strong assessment tools; however, these tools are often developed solely for research use, not practitioner application. In the following, using our assessment battery as an example, we will discuss the steps necessary to adapt SEL assessment for computer-based administration and optimal utility in early childhood education programs.

Childhood cancer survivor satisfaction with characteristics of clinical care

This study investigated the characteristics of a clinic that affect how satisfied survivors of childhood cancer are with their medical care. Questionnaire and interview data from the Passport for Care: Texas Implementation project collected between January 2011 to April 2012 were analyzed. Eleven clinics in Texas participated. Questionnaire respondents were childhood cancer survivor patients who had been off therapy for at least 2 years, or their parents. Interview respondents were clinical providers or research staff at the participating clinics. The outcomes evaluated were answers to a single question on satisfaction with care and a composite Percent Satisfaction Score created from seven other questionnaire items that were correlated (Spearman Rho >0.3) with the question on satisfaction. The following characteristics were also evaluated: sex, age, race, education, and type of cancer. The following clinic indicators were evaluated: type of clinic (general vs. dedicated cancer survivor clinics), number of providers, number of survivors, ratio of survivors/providers, distribution of handouts, distribution of treatment summaries, and use of Children's Oncology Group (COG) guidelines. ^ The only demographic characteristic that affected satisfaction was race. A Kruskal-Wallis test showed a statistically significant difference (Chi-square 6.129, 2 d.f., p = 0.0467). To analyze this further, Wilcoxon Rank Sum test of pairings of the three groups were performed. A Bonferroni correction for multiple testing was applied, with p = 0.017 indicating significance at alpha = 0.05. There was no significant difference between the White and Hispanic groups or between the Hispanic and "Other" groups. For the White and "Other" groups there was a significant difference for the satisfaction item (p = 0.0123) but not for the Percent Satisfaction Score (p = 0.0289). These results suggest that race may influence satisfaction and should be evaluated further in future studies. ^ None of the clinic indicators affected the Percent Satisfaction Score. Going to a clinic that distributed patient information handouts (Wilcoxon Rank Sum p = 0.048) and going to a clinic with >=100 survivors (Wilcoxon Rank Sum p = 0.021) were associated with increased satisfaction. The population of childhood cancer survivors is a growing group of individuals with special health needs. In the future survivors will likely seek medical care in a variety of clinical settings, so it is important to investigate features to improve patient satisfaction with clinical care.^