{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T20:30:31Z","timestamp":1789504231167,"version":"build-2803163510"},"reference-count":65,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2023,10,6]],"date-time":"2023-10-06T00:00:00Z","timestamp":1696550400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Crocker Family Fellowship at the University of Massachusetts-Boston"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background: Healthy People 2030 emphasizes personal health literacy (individual skills) and organizational health literacy\u2014the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. However, research on the latter is in the early stages. Methods: This study describes an organizational health literacy assessment in a U.S. urban academic children\u2019s hospital. A variety of evidence-based health literacy assessments were used to assess patient information materials and the environment, including institutional practices, navigation, culture and language, and communication. Trained interviewers and analysts reached consensus for all assessments. Results: Information Items: SMOG scores (n = 9) ranged from 7th- to 14th-grade reading level (average = 11.3). PEMAT-P scores (n = 9) ranged from 43.8% to 93.8% understandability and 0% to 80% actionability. CDC CCI scores (literacy demand) (n = 6) ranged from 18.2% to 58.8% (\u226590% = excellent). SAM scores (suitability) (n = 6) fell in the \u201cadequate\u201d range (43.2\u201358.3%). The PMOSE\/IKIRSCH scores (complexity) (n = 3) noted low-moderate difficulty. Apter\u2019s Hierarchy (n = 4) revealed three numeracy domains (50% = descriptive purposes and decision-making, 100% = interpreting information). Organization-level: Walking interviews highlighted organizational facilitators and barriers related to the pre-visit and visit environments. HLE2 domain scores ranged from 52% to 68%. Conclusions: Organizational health literacy demands far outweigh the average literacy skills of adults in the U.S. (patients and staff). Findings can be used to hone quality improvement and other processes to focus on structural solutions to increase health equity.<\/jats:p>","DOI":"10.3390\/children10101658","type":"journal-article","created":{"date-parts":[[2023,10,7]],"date-time":"2023-10-07T14:17:26Z","timestamp":1696688246000},"page":"1658","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["Organizational Health Literacy as a Tool for Health Equity: Application in a High-Risk Infant Follow-Up Program"],"prefix":"10.3390","volume":"10","author":[{"given":"Lindsay E.","family":"Rosenfeld","sequence":"first","affiliation":[{"name":"Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA"},{"name":"Boston Children\u2019s Hospital, Boston, MA 02115, USA"},{"name":"Heller School for Social Policy & Management, Brandeis University, Waltham, MA 02453, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kelly","family":"McCullagh","sequence":"additional","affiliation":[{"name":"Boston Children\u2019s Hospital, Boston, MA 02115, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carolyn J.","family":"King","sequence":"additional","affiliation":[{"name":"Boston Children\u2019s Hospital, Boston, MA 02115, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Micaela","family":"Torres","sequence":"additional","affiliation":[{"name":"Charles R. Drew, UCLA Medical Education Program, Los Angeles, CA 90059, USA"},{"name":"UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8748-2449","authenticated-orcid":false,"given":"Jonathan S.","family":"Litt","sequence":"additional","affiliation":[{"name":"Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA"},{"name":"Boston Children\u2019s Hospital, Boston, MA 02115, USA"},{"name":"Beth Israel Deaconess Medical Center, Boston, MA 02215, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,10,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1016\/S0140-6736(17)30569-X","article-title":"Structural racism and health inequities in the USA: Evidence and interventions","volume":"389","author":"Bailey","year":"2017","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1089\/jwh.2020.8882","article-title":"Social and Structural Determinants of Health Inequities in Maternal Health","volume":"30","author":"Johnson","year":"2021","journal-title":"J. Women\u2019s Health"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Weinstein, J.N., Geller, A., Negussie, Y., and Baciu, A. (2017). Communities in Action: Pathways to Health Equity, National Academies Press.","DOI":"10.17226\/24624"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Whitman, A., De Lew, N., Chappel, A., Aysola, V., Zuckerman, R., and Sommers, B.D. (2022). Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts, ASPE\u2014Office of Health Policy.","DOI":"10.1001\/jamahealthforum.2022.1064"},{"key":"ref_5","unstructured":"CDC\u2019s Patient Navigation (2023, July 20). Centers for Disease Control and Prevention, Cancer Resources for Clinics and Communities. 10 July 2023, Available online: https:\/\/www.cdc.gov\/cancer\/community-resources\/interventions\/patient-navigation.htm."},{"key":"ref_6","unstructured":"Bolan, M. (2023, September 19). Housing and Employment Navigator Program Evaluation. Department of Labor Workforce Innovation Fund Grant, June 2017. Available online: https:\/\/buildingchanges.org\/wp-content\/uploads\/2017\/07\/2017_HousingandEmploymentNavigator_Findings.pdf."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Lopez, C., Kim, B., and Sacks, K. (2023, September 19). Health Literacy in the United States: Enhancing Assessments and Reducing Disparities. Milken Institute, 2022. Available online: https:\/\/milkeninstitute.org\/sites\/default\/files\/2022-05\/Health_Literacy_United_States_Final_Report.pdf.","DOI":"10.2139\/ssrn.4182046"},{"key":"ref_8","first-page":"1","article-title":"Health literacy interventions and outcomes: An updated systematic review","volume":"199","author":"Berkman","year":"2011","journal-title":"Evid. Report\/Technol. Assess."},{"key":"ref_9","unstructured":"Institute of Medicine (US) Committee on Health Literacy (2023, July 24). Health Literacy: A Prescription to End Confusion, Available online: http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK216032\/."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e379","DOI":"10.3399\/bjgp15X685285","article-title":"A mismatch between population health literacy and the complexity of health information: An observational study","volume":"65","author":"Rowlands","year":"2015","journal-title":"Br. J. Gen. Pract."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Baumeister, A., Chakraverty, D., Aldin, A., Seven, \u00dc.S., Skoetz, N., Kalbe, E., and Woopen, C. (2021). \u2018The system has to be health literate, too\u2019\u2014Perspectives among healthcare professionals on health literacy in transcultural treatment settings. BMC Health Serv. Res., 21.","DOI":"10.1186\/s12913-021-06614-x"},{"key":"ref_12","first-page":"e167","article-title":"Performing an Organizational Health Literacy Assessment in a Shelter Serving People with Mental Illness","volume":"6","author":"Rosenfeld","year":"2022","journal-title":"HLRP Health Lit. Res. Pract."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1177\/00333549141291S206","article-title":"The Social Determinants of Health: It\u2019s Time to Consider the Causes of the Causes","volume":"129","author":"Braveman","year":"2014","journal-title":"Public Health Rep."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"367","DOI":"10.1146\/annurev-publhealth-090810-182459","article-title":"Prematurity: An Overview and Public Health Implications","volume":"32","author":"McCormick","year":"2011","journal-title":"Annu. Rev. Public Health"},{"key":"ref_15","unstructured":"(2023, July 24). Healthy People 2030, Available online: https:\/\/health.gov\/healthypeople."},{"key":"ref_16","unstructured":"CDC\u2019s Health Literacy (2023, July 20). Centers for Disease Control and Prevention. 10 July 2023, Available online: https:\/\/www.cdc.gov\/healthliteracy\/index.html."},{"key":"ref_17","unstructured":"Commission, T.J. (2023, September 19). \u2018What Did the Doctor Say?\u2019: Improving Health Literacy to Protect Patient Safety. Available online: https:\/\/swselfmanagement.ca\/uploads\/ResourceDocuments\/The%20Joint%20Commission%20(2007)%20Improving%20Health%20Literacy%20for%20Patient%20Safety.pdf."},{"key":"ref_18","unstructured":"(2023, July 20). FY 2021 Grant Awards\u2014The Office of Minority Health, Available online: https:\/\/www.minorityhealth.hhs.gov\/omh\/browse.aspx?lvl=2&lvlid=88."},{"key":"ref_19","unstructured":"(2023, July 24). Health Literacy in Healthy People 2030\u2014Healthy People 2030, Available online: https:\/\/health.gov\/healthypeople\/priority-areas\/health-literacy-healthy-people-2030."},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"Batool, S.H., Safdar, M., and Eman, S. (Libr. Hi Tech, 2022). Relationship between parents\u2019 health literacy and child health: Systematic review, Libr. Hi Tech, ahead-of-print.","DOI":"10.1108\/LHT-11-2021-0398"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Keim-Malpass, J., Letzkus, L.C., and Kennedy, C. (2015). Parent\/caregiver health literacy among children with special health care needs: A systematic review of the literature. BMC Pediatr., 15.","DOI":"10.1186\/s12887-015-0412-x"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"131","DOI":"10.1001\/archpediatrics.2008.539","article-title":"Literacy and Child Health: A Systematic Review","volume":"163","author":"Sanders","year":"2009","journal-title":"Arch. Pediatr. Adolesc. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"S265","DOI":"10.1542\/peds.2009-1162B","article-title":"Health literacy and child health outcomes: A systematic review of the literature","volume":"124","author":"DeWalt","year":"2009","journal-title":"Pediatrics"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1016\/j.acap.2010.06.007","article-title":"Parental Understanding of Infant Health Information: Health Literacy, Numeracy, and the Parental Health Literacy Activities Test (PHLAT)","volume":"10","author":"Kumar","year":"2010","journal-title":"Acad. Pediatr."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"7411510280p1","DOI":"10.5014\/ajot.2020.74S1-PO3121","article-title":"Impact of Health Literacy on Early Intervention (EI) Access and Utilization: A Scoping Review","volume":"74","author":"Leslie","year":"2020","journal-title":"Am. J. Occup. Ther."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1017\/dmp.2019.62","article-title":"An Evaluation of the Literacy Demands of Online Natural Disaster Preparedness Materials for Families","volume":"14","author":"So","year":"2020","journal-title":"Disaster Med. Public Health Prep."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"\u015awi\u0105tkiewicz-Mo\u015bny, M., Prokop-Dorner, A., \u015alusarczyk, M., O\u017cegalska-\u0141ukasik, N., Pi\u0142at-Kobla, A., Zaj\u0105c, J., and Bala, M.M. (2022). When Peppa Pig and Confucius meet, joining forces on the battlefield of health literacy\u2013a qualitative analysis of COVID-19 educational materials for children and adolescents from China, the USA, and Europe. PLoS ONE, 17.","DOI":"10.1371\/journal.pone.0278554"},{"key":"ref_28","unstructured":"National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, and Roundtable on Health Literacy (2023, August 18). Developing Health Literacy Skills in Children and Youth: Proceedings of a Workshop, The National Academies Collection: Reports Funded by National Institutes of Health, Available online: http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK562692\/."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Naccarella, L., and Guo, S. (2022). A Health Equity Implementation Approach to Child Health Literacy Interventions. Children, 9.","DOI":"10.3390\/children9091284"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1016\/j.ssmph.2016.06.005","article-title":"Making health information meaningful: Children\u2019s health literacy practices","volume":"2","author":"Fairbrother","year":"2016","journal-title":"SSM Popul. Health"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Rosenfeld, L., and Litt, J.S. (Fam. Syst. Health, 2023). To Achieve Equitable, Integrated Care for Children, Family-centered Work Must Focus on Systems, Fam. Syst. Health, in press.","DOI":"10.1037\/fsh0000809"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1542\/pir.2018-0027","article-title":"Health Literacy: Implications for Child Health","volume":"40","author":"Morrison","year":"2019","journal-title":"Pediatr. Rev."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"S327","DOI":"10.1542\/peds.2009-1162I","article-title":"Health Literacy and Children: Recommendations for Action","volume":"124","author":"Abrams","year":"2009","journal-title":"Pediatrics"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1179\/1753807611Y.0000000005","article-title":"Results of a feasibility study to assess the health literacy environment: Navigation, written, and oral communication in 10 hospitals in Catalonia, Spain","volume":"4","author":"Groene","year":"2011","journal-title":"J. Commun. Healthc."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e85","DOI":"10.2105\/AJPH.2014.302036","article-title":"Health Literacy Environmental Scans of Community-Based Dental Clinics in Maryland","volume":"104","author":"Horowitz","year":"2014","journal-title":"Am. J. Public Health"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"113","DOI":"10.2147\/NBHIV.S36549","article-title":"Baseline medication adherence and response to an electronically delivered health literacy intervention targeting adherence","volume":"4","author":"Ownby","year":"2012","journal-title":"Neurobehav. HIV Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"974","DOI":"10.1080\/10810730.2012.757395","article-title":"Iterative evaluation of a web-based health information resource","volume":"18","author":"Rosenfeld","year":"2013","journal-title":"J. Health Commun."},{"key":"ref_38","first-page":"20","article-title":"Interventions to Improve Care for Patients with Limited Health Literacy","volume":"16","author":"Sudore","year":"2009","journal-title":"J. Clin. Outcomes Manag."},{"key":"ref_39","first-page":"60","article-title":"Health Literacy: Insights and Issues","volume":"240","author":"Rudd","year":"2017","journal-title":"Stud. Health Technol. Inform."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"e287","DOI":"10.1097\/pq9.0000000000000287","article-title":"Optimizing High-risk Infant Follow-up in Nonresearch-based Paradigms: The New England Follow-up Network","volume":"5","author":"Litt","year":"2020","journal-title":"Pediatr. Qual. Saf."},{"key":"ref_41","first-page":"1391","article-title":"Preterm infants are less likely to have a family-centered medical home than term-born peers","volume":"38","author":"Litt","year":"2018","journal-title":"J. Perinatol. Off. J. Calif. Perinat. Assoc."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"(2004). Follow-up Care of High-Risk Infants. Pediatrics, 114, 1377\u20131397.","DOI":"10.1542\/peds.2004-0866"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e2022057865","DOI":"10.1542\/peds.2022-057865","article-title":"Racial Inequity in High-Risk Infant Follow-Up Among Extremely Low Birth Weight Infants","volume":"151","author":"Fraiman","year":"2023","journal-title":"Pediatrics"},{"key":"ref_44","first-page":"217","article-title":"Race, language, and neighborhood predict high-risk preterm Infant Follow Up Program participation","volume":"42","author":"Fraiman","year":"2022","journal-title":"J. Perinatol. Off. J. Calif. Perinat. Assoc."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1093\/intqhc\/mzm042","article-title":"Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups","volume":"19","author":"Tong","year":"2007","journal-title":"Int. J. Qual. Health Care"},{"key":"ref_46","first-page":"639","article-title":"SMOG Grading\u2014A New Readability Formula","volume":"12","author":"Laughlin","year":"1969","journal-title":"J. Read."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Doak, C.C., Doak, L.G., and Root, J.H. (1996). Teaching Patients with Low Literacy Skills, JB Lippincott Company.","DOI":"10.1097\/00000446-199612000-00022"},{"key":"ref_48","first-page":"638","article-title":"A New Measure of Assessing Document Complexity: The PMOSE\/IKIRSCH Document Readability Formula","volume":"41","author":"Mosenthal","year":"1998","journal-title":"J. Adolesc. Adult Lit."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1016\/j.pec.2014.05.027","article-title":"Development of the Patient Education Materials Assessment Tool (PEMAT): A new measure of understandability and actionability for print and audiovisual patient information","volume":"96","author":"Shoemaker","year":"2014","journal-title":"Patient Educ. Couns."},{"key":"ref_50","unstructured":"CDC (2023, August 18). The CDC Clear Communication Index. Centers for Disease Control and Prevention. 28 June 2023, Available online: https:\/\/www.cdc.gov\/ccindex\/index.html."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"2117","DOI":"10.1007\/s11606-008-0803-x","article-title":"Numeracy and Communication with Patients: They Are Counting on Us","volume":"23","author":"Apter","year":"2008","journal-title":"J. Gen. Intern. Med."},{"key":"ref_52","unstructured":"Rudd, R. (2023, September 19). Health Literacy Environment Activity Packet: First Impressions and Walking Interview. Available online: https:\/\/www.hsph.harvard.edu\/wp-content\/uploads\/sites\/135\/2012\/09\/activitypacket.pdf."},{"key":"ref_53","unstructured":"Labra, O., Castro, C., Wright, R., and Chamblas, I. (2019). Global Social Work\u2014Cutting Edge Issues and Critical Reflections, IntechOpen."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1348\/000712600161646","article-title":"Objectivity and reliability in qualitative analysis: Realist, contextualist and radical constructionist epistemologies","volume":"91","author":"Madill","year":"2000","journal-title":"Br. J. Psychol."},{"key":"ref_55","unstructured":"Liamputtong, P., and Ezzy, D. (2023, August 18). Qualitative Research Methods, Available online: http:\/\/catdir.loc.gov\/catdir\/enhancements\/fy0637\/2005276163-t.html."},{"key":"ref_56","unstructured":"Rudd, R., Oelschlegel, S., Tester, E., Heidel, E., and The Health Literacy Task Force of the University of Tennessee Medical Center (2023, September 19). The Health Literacy Environment of Hospitals and Health Centers. Available online: https:\/\/www.hsph.harvard.edu\/wp-content\/uploads\/sites\/135\/2019\/05\/april-30-FINAL_The-Health-Literacy-Environment2_Locked.pdf."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1089\/ped.2013.0237","article-title":"Provider Perceptions of Parent Health Literacy and Effect on Asthma Treatment Recommendations and Instructions","volume":"26","author":"Harrington","year":"2013","journal-title":"Pediatr. Allergy Immunol. Pulmonol."},{"key":"ref_58","doi-asserted-by":"crossref","unstructured":"Schappin, R., Wijnroks, L., Uniken Venema, M.M.A.T., and Jongmans, M.J. (2013). Rethinking stress in parents of preterm infants: A meta-analysis. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0054992"},{"key":"ref_59","unstructured":"Rudd, R. (2023, August 18). Background and Overview, Implications of Health Literacy for Public Health: Workshop Summary, Available online: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK242431\/."},{"key":"ref_60","unstructured":"(2023, August 18). Strategies to Improve Organizational Health Literacy. Sep, Available online: https:\/\/psnet.ahrq.gov\/primer\/strategies-improve-organizational-health-literacy."},{"key":"ref_61","unstructured":"(2023, August 18). AHRQ Health Literacy Universal Precautions Toolkit, Available online: https:\/\/www.ahrq.gov\/health-literacy\/improve\/precautions\/index.html."},{"key":"ref_62","unstructured":"(2023, August 18). The Roles of Trust and Health Literacy in Achieving Health Equity A Workshop Series. National Academies. Available online: https:\/\/www.nationalacademies.org\/our-work\/the-roles-of-trust-and-health-literacy-in-achieving-health-equity-a-workshop-series."},{"key":"ref_63","unstructured":"Rothwell, J. (2023, September 19). Assessing the Economic Gains of Eradicating Illiteracy Nationally and Regionally in the United States. Barbara Bush Foundation for Family Literacy, 2020. Available online: https:\/\/www.barbarabush.org\/wp-content\/uploads\/2020\/09\/BBFoundation_GainsFromEradicatingIlliteracy_9_8.pdf."},{"key":"ref_64","doi-asserted-by":"crossref","unstructured":"Brach, C., Keller, D., Hernandez, L.M., Baur, C., Parker, R., Dreyer, B., Schyve, P., Lemerise, A.J., and Schillinger, D. (2012). Ten Attributes of Health Literate Health Care Organizations, National Academy of Sciences.","DOI":"10.31478\/201206a"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1001\/jamainternmed.2023.2558","article-title":"Health Literacy and Systemic Racism-Using Clear Communication to Reduce Health Care Inequities","volume":"183","author":"Coleman","year":"2023","journal-title":"JAMA Intern. Med."}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/10\/10\/1658\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T21:02:11Z","timestamp":1760130131000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/10\/10\/1658"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,10,6]]},"references-count":65,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2023,10]]}},"alternative-id":["children10101658"],"URL":"https:\/\/doi.org\/10.3390\/children10101658","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,10,6]]}}}