Publications
Peer-reviewed publications
2026
- Days at Home among Children by Medical Complexity, Public/Private Insurance and Urban/Rural ResidenceCaleb W. Easterly , Laura Stilwell , Justin Trogdon , and 2 more authorsAcademic Pediatrics, 2026
Objective: Days at home (DAH; days without a medical encounter) is a patient- and family-centered measure that has not been used among children with medical complexity (CMC). Our objective was to pilot the DAH measure among CMC and compare DAH between those insured by private and public insurance plans. Methods: This retrospective cohort study used 2017–2019 medical claims data from NC Medicaid/Children’s Health Insurance Program and a large NC-based private insurer. Beneficiary-years were included for beneficiaries aged 1–20 years and continuously enrolled for 12 months. CMC were identified with the Pediatric Medical Complexity Algorithm. Annual DAH was calculated as 365 minus the number of days with any medical encounter. We evaluated how adjusted DAH varied by medical complexity, payer, and urban/rural residence. Results: Compared to children without chronic disease, CMC insured by Medicaid and private insurance had 17.6 (99.9% CI: 17.4, 17.7) and 15.9 (99.9% CI: 15.4, 16.4) fewer DAH, respectively. Medicaid-insured CMC had 2.92 fewer annual DAH than privately insured CMC after adjusting for age, sex, and rurality, though this decreased to 0.45 fewer annual DAH after additionally adjusting for body systems affected by the health condition(s). Both privately and publicly insured CMC living in rural areas had more DAH than those living in large metropolitan areas. Conclusions: CMC have fewer DAH than children without chronic disease. Differences in DAH by payer and rurality could be due to disease severity, differential access to medical care, or variation in the quality of health care obtained by children and their families.
2025
- Money or Time? Heterogenous Effects of Unconditional Cash on Parental InvestmentsHema Shah , Lisa A Gennetian , Katherine Magnuson , and 4 more authorsNational Bureau of Economic Research, Working Paper 33737, 2025
Household time and money allocations in response to income support programs vary across diverse family circumstances and preferences, yet such heterogeneous responses are not well understood. Using data from a large-scale, multisite, U.S.-based randomized controlled study, we examine heterogeneity in the effects of a monthly unconditional cash transfer on monetary and time investments in children. This study offers a novel opportunity to examine heterogeneous effects of a cash transfer by race and ethnicity, where receipt is independent of eligibility based on other demographic characteristics. The effects of the cash transfer on net household income, earnings, and household expenditures were similar for families irrespective of race or ethnicity, even given initial differences in family structure, government benefit receipt, and employment. However, effects on monetary and time investments in children differed. Latino families’ child-focused expenditures increased, equivalent to nearly one-third of the cash transfer, with no effect on maternal employment or time spent with children. Among Black families, maternal work hours decreased and time spent with children on early learning activities increased, with no effect on child-focused expenditures. Marginal propensities to consume child-specific goods from different income sources also varied: Estimates showed a higher marginal propensity to consume child-specific goods from government income than from maternal income among Latino families, and the opposite among Black families. Latino families’ responses to the unconditional cash transfer and to government income are consistent with the notion that signals regarding intended use of income influence spending decisions.
- Breastfeeding measurement: Choosing a Scale to Measure Breastfeeding Attitudes and BeliefsSidra Mazhar , Laura Stilwell , Zoha Waqar Farooqi , and 1 more authorJournal of Human Lactation, 2025
The World Health Organization recommends exclusive breastfeeding for the first six months of life and continued breastfeeding for up to two years. A mother’s ability to initiate and sustain breastfeeding is shaped by complex individual- and community-level attitudes, beliefs, and knowledge, making it challenging to measure these factors across diverse contexts. This paper presents a comprehensive overview of existing instruments that assess breastfeeding attitudes, beliefs, and knowledge to facilitate the selection of appropriate tools, building upon existing reviews that have examined validated instruments for attitudes, knowledge, self-efficacy, and social support. This review aims to support researchers, program designers, and policymakers in choosing tools that align with their specific objectives, populations, and theoretical frameworks. A curated selection of validated instruments is presented in table format, highlighting constructs such as self-efficacy, attitudes, and beliefs. These tools were selected based on their relevance to general maternal populations, use in peer-reviewed research, and applicability across the breastfeeding continuum. Key domains included in the table are the construct measured, item format and scoring, considerations for tool selection, and examples of translation and cultural adaptation. Included instruments are psychometrically robust with established validity and reliability, and many have been adapted for and tested in diverse cultural settings. The table reveals that while many instruments demonstrate strong reliability and validity, their scope, cultural adaptability, and focus across the breastfeeding timeline vary considerably.
2024
- Unconditional Cash and Breastfeeding, Child Care, and Maternal Employment among Families with Young Children Residing in PovertyLaura Stilwell , Maritza Morales-Gracia , Katherine Magnuson , and 6 more authorsSocial Service Review, 2024
Poverty interferes with parents’ breastfeeding, child-care, and employment options and ability to meet their parenting goals. This study—the first randomized controlled trial of early childhood poverty reduction in the United States—investigates how increased economic resources affect 1,000 low-income US mothers’ breastfeeding, child-care, and employment practices and the ability to meet their intentions for these practices in the first year of their infant’s life. The likelihood and length of breastfeeding, use of nonparental child care, and maternal employment did not statistically differ among mothers who received a high (333) or low (20) monthly unconditional cash gift. The higher monthly cash gift, however, delayed the starting age of child care by almost 1 month and increased mothers’ ability to meet their breastfeeding intentions reported at birth.
- Monthly unconditional income supplements starting at birth: Experiences among mothers of young children with low incomes in the USSarah Halpern-Meekin , Lisa A Gennetian , Jill Hoiting , and 2 more authorsJournal of Policy Analysis and Management, 2024
Recently, U.S. advocates and funders have supported direct cash transfers for individuals and families as an efficient, immediate, and non-paternalistic path to poverty alleviation. Open questions remain, however, about their implementation. We address these using data from debit card transactions, customer service call-line logs, and in-depth interviews from a randomized control study of a monthly unconditional cash gift delivered via debit card to mothers of young children living near the federal poverty line. Because much of the impact of the intervention occurs through mothers’ decisions about how to allocate the Baby’s First Years (BFY) money, we argue that implementation science must recognize the role of policy targets in implementing policy, not just in terms of policy outcomes but also policy implementation processes. Further, our analysis shows that mothers experience key aspects of the cash intervention’s design as intended: they viewed the cash gift as unconditional and knew the money was reliable and would continue monthly, receiving the correct amount with few incidents. Delivering funds via debit card worked well, offering mothers flexibility in purchasing. We also illuminate how design features shaped mothers’ experiences. First, although they knew it was unconditional, the social meaning of the BFY money to mothers—seen as “the baby’s money”—shaped their engagement with and allocation of it. Second, low public visibility of mothers’ receipt of this money limited the financial demands or requests from others, potentially facilitating more agency over and a greater ability to use the money as they chose, without claims from kin.
2022
- Electronic health record tools to identify child maltreatment: scoping literature review and key informant interviewsLaura Stilwell , Megan Golonka , Kristin Ankoma-Sey , and 4 more authorsAcademic Pediatrics, 2022
To prevent missed cases and standardize care, health systems are beginning to implement EHR-based screens (EHR-CA-S) and clinical decision supports systems (EHR-CA-CDSS) for the identification and management of child maltreatment. This study aimed to 1) document the existing research evidence on the performance of EHR-CA-S and EHR-CA-CDSS and 2) examine clinical perspectives regarding the use of such tools and factors that affect uptake. We searched MEDLINE, Embase, EBSCO, Scopus, and CINAHL databases for English language articles published prior to November 2021 that describe and/or evaluated an EHR-CA-S and/or EHR-CA-CDSS involving 0 to 18-year olds. We performed semistructured interviews with 20 individuals who have experience in identifying, evaluating, and/or treating child maltreatment and/or conducting research on these topics. Our search identified 574 articles; 16 met inclusion criteria. Studies examined screening, alerts and triggers, and quality improvement. None evaluated long-term clinical outcomes. Sensitivity ranged from 0.14 to 1.00, specificity from 0.865 to 1.00, positive predictive value from 0.03 to 1.00 and negative predictive value from 0.55 to 1.00. A variety of EHR-CA-S and/or EHR-CA-CDSS have been implemented at institutions in our sample. Interviewees cited missed cases, policy requirements, and the lack of standardization of care as impetuses for adopting these tools, yet expressed concerns regarding insufficient evidence, bias, and time-intensiveness of implementation. Interviewees and the literature agree that current evidence does not support adoption of a particular CA-S or CA-CDSS. Further refinement and research on EHR-CA-S and EHR-CA-CDSS is necessary for these tools to be feasibly implemented and sustained, reliable for clinical practice, and not cause any unintentional harms.
@article{stilwell2022electronic, title = {Electronic health record tools to identify child maltreatment: scoping literature review and key informant interviews}, author = {Stilwell, Laura and Golonka, Megan and Ankoma-Sey, Kristin and Yancy, Madeleine and Kaplan, Samantha and Terrell, Lindsay and Gifford, Elizabeth J}, journal = {Academic Pediatrics}, volume = {22}, number = {5}, pages = {718--728}, year = {2022}, publisher = {Elsevier}, } - What do child abuse and neglect medical evaluation consultation notes tell researchers and clinicians?Megan Golonka , Yuerong Liu , Rosie Rohrs , and 10 more authorsChild Maltreatment, 2022
Child abuse and neglect (CAN) medical experts provide specialized multidisciplinary care to children when there is concern for maltreatment. Their clinical notes contain valuable information on child- and family-level factors, clinical concerns, and service placements that may inform the needed supports for the family. We created and implemented a coding system for data abstraction from these notes. Participants were 1,397 children ages 0–17 years referred for a consultation with a CAN medical provider at an urban teaching and research hospital between March 2013 and December 2017. Coding themes were developed using an interdisciplinary team-based approach to qualitative analysis, and descriptive results are presented using a developmental-contextual framework. This study demonstrates the potential value of developing a coding system to assess characteristics and patterns from CAN medical provider notes, which could be helpful in improving quality of care and prevention and detection of child abuse.
@article{golonka2022child, title = {What do child abuse and neglect medical evaluation consultation notes tell researchers and clinicians?}, author = {Golonka, Megan and Liu, Yuerong and Rohrs, Rosie and Copeland, Jennifer and Byrd, Jessalyn and Stilwell, Laura and Crew, Carter and Kuehn, Molly and Snyder-Fickler, Elizabeth and Hurst, Jillian H and Evans, Kelly E and Terrell, Lindsay and Gifford, Elizabeth J}, journal = {Child Maltreatment}, pages = {10775595221134537}, year = {2022}, publisher = {SAGE Publications Sage CA: Los Angeles, CA}, } - Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample?Yuerong Liu , Megan Shepherd-Banigan , Kelly E Evans , and 4 more authorsChild Abuse & Neglect, 2022
Background: Child maltreatment leads to substantial adverse health outcomes, but little is known about acute health care utilization patterns after children are evaluated for a concern of maltreatment at a child abuse and neglect medical evaluation clinic.
Objective: To quantify the association of having a child maltreatment evaluation with subsequent acute health care utilization among children from birth to age three.
Participants and setting: Children who received a maltreatment evaluation (N = 367) at a child abuse and neglect subspecialty clinic in an academic health system in the United States and the general pediatric population (N = 21,231).
Methods: We conducted a retrospective cohort study that compared acute health care utilization over 18 months between the two samples using data from electronic health records. Outcomes were time to first emergency department (ED) visit or inpatient hospitalization, maltreatment-related ED use or inpatient hospitalization, and ED use or inpatient hospitalization for ambulatory care sensitive conditions (ACSCs). Multilevel survival analyses were performed.
Results: Children who received a maltreatment evaluation had an increased hazard for a subsequent ED visit or inpatient hospitalization (hazard ratio [HR]: 1.3, 95% confidence interval [CI]: 1.1, 1.5) and a maltreatment-related visit (HR: 4.4, 95% CI: 2.3, 8.2) relative to the general pediatric population. A maltreatment evaluation was not associated with a higher hazard of health care use for ACSCs (HR: 1.0, 95% CI: 0.7, 1.3).
Conclusion: This work can inform targeted anticipatory guidance to aid high-risk families in preventing future harm or minimizing complications from previous maltreatment.@article{liu2022children, title = {Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample?}, author = {Liu, Yuerong and Shepherd-Banigan, Megan and Evans, Kelly E and Stilwell, Laura and Terrell, Lindsay and Hurst, Jillian H and Gifford, Elizabeth J}, journal = {Child Abuse \& Neglect}, volume = {134}, pages = {105938}, year = {2022}, publisher = {Elsevier}, }
Policy briefs & commentaries
2025
- The Effects of Monthly Unconditional Cash Support Among Latina FamiliesLisa A. Gennetian , Hema Shah , Luis E. Basarto , and 8 more authorsHispanic Research Center, 2025
To provide broader context for findings on how the Baby’s First Years cash gift intervention affected Latina families, we first summarize findings on economic outcomes and family investments on child-specific goods and time for the full sample. BFY families represent a wide variety of ethnic and racial backgrounds and experiences. These background characteristics and experiences—including historical and contemporary economic, political, and social service contexts—affect the ways in which families can and choose to use the BFY cash gift to support their economic well-being and family investments.
2023
- Methodology and interpretation of recent Rebbe et al paperLaura R. Stilwell , and Darcy H. MerrittThe Journal of Pediatrics, 2023
@article{stilwell2023methodology, title = {Methodology and interpretation of recent Rebbe et al paper}, author = {Stilwell, Laura R. and Merritt, Darcy H.}, journal = {The Journal of Pediatrics}, volume = {261}, year = {2023}, publisher = {Elsevier}, } - Landscape of Early Childhood Housing Instability & Homelessness in North Carolina and Recommendations to Address Unmet NeedsLaura Stilwell , Ainsley Buck , Stephanie Green , and 7 more authorsMargolis Center for Health Policy, Duke University, 2023
- What We Know About Current Electronic Health Record Tools for the Identification and Management of Child AbuseLaura Stilwell , Megan Golonka , Kristin Ankoma-Sey , and 5 more authorsCenter for Child & Family Policy, Duke University, 2023
- Children Evaluated for Maltreatment Have Higher Subsequent Emergency Department and Inpatient Care Utilization than the General Pediatric PopulationYuerong Liu , Megan Shepherd-Banigan , Kelly E. Evans , and 4 more authorsCenter for Child & Family Policy, Duke University, 2023
2022
- Economics of Infant Feeding in the U.S.Laura R. Stilwell , and Lisa A. GennetianEconofact, 2022