Primary health care for Hispanic children of migrant farm workers.

Providing primary care to children of culturally diverse populations is a challenge for pediatric nurse practitioners and educators. The challenge is intensified when providing care to Hispanic children who are uprooted because their parent(s) are migrant farm workers. The creation of health-focused academic community partnerships is one unique strategy to improve primary care to these children. One such partnership is the ongoing Migrant Family Health Program in which practitioner nursing students and their faculty members provide primary health care to children who are enrolled in a summer education program for migrant children.     

Redefining primary pediatric care for children with special health care needs: the primary care medical home

PURPOSE OF REVIEW: As considerations of the quality of health care have matured, the role of pediatric primary care providers and models for the delivery of primary care have received growing attention. Particularly for children with chronic conditions, the need for proactive, planned, and coordinated care delivered in partnership with consumers has become more apparent. The primary care medical home has emerged as a model favored by national organizations representing pediatricians and family physicians as well as national public health policy makers, yet implementation of this model remains limited and the evidence base for its value is not yet highly developed. RECENT FINDINGS: Most studies of primary care outcomes involve individual elements of the medical home such as care coordination and continuity of care. Limited data that are emerging from studies of the medical home model as a whole in practice settings suggest improvements in patient satisfaction and in some areas of utilization. No data are available that examine specific functional or physical health outcomes associated with primary care models like the medical home. SUMMARY: The pediatric primary care medical home provides a care model for both well children and those with special health care needs that expands primary care services beyond those provided in the examination room by individual providers to include systemic services such as patient registries, explicit care planning and care coordination, planned co-management with specialists, patient advocacy, and patient education. There is an immediate need for large-scale, practice-based studies of the outcomes for children and youth, providers, and the health care system when such improvements in primary care are implemented.     

Parent's language of interview and access to care for children with special health care needs.

OBJECTIVE: To examine the association between the parent's language of interview and the access to care for children with special health care needs (CSHCN). METHODS: We used the 2001 National Survey of Children with Special Health Care Needs to compare socio-demographic characteristics and health care access variables among CSHCN with parents who interviewed in English and another language. Additional multivariate analyses explored the effect of language of interview on access to health care for the subgroup of Hispanic respondents. RESULTS: CSHCN with non-English-speaking parents were from less-educated and lower-income families and were more likely to lack insurance and have conditions that greatly affected their activities. These children were also more likely to have inadequate insurance (odds ratio [OR]=11.29), have an unmet need for family support services (OR=1.88), lack a personal doctor or nurse (OR=1.98), lack a usual source of care (OR=1.89), and lack family-centered care (OR=1.74). Non-English-speaking parents were more likely to report having employment consequences (OR=1.94) and spending over $500 out-of-pocket annually on the child's health care needs (OR=1.49). The likelihood of Hispanic children experiencing health care access barriers compared with non-Hispanic children was reduced when language was controlled for and several disparities between Hispanic children and other children became insignificant. CONCLUSIONS: CSHCN with non-English-speaking parents were more likely to be from disadvantaged families and to experience barriers to access than were CSHCN with English-speaking parents. Systems of care for CSHCN should consider the needs and challenges experienced by families whose primary language is not English.     

Improving health insurance and access to care for children in immigrant families.

Children in immigrant families now comprise more than one-fifth of all children in the United States. Low-income children in immigrant families, particularly children who are themselves immigrants, are more likely to be uninsured and to have poor access to health care than low-income children from native-born families. Differences in insurance coverage are related to restricted eligibility for public insurance coverage and to limited access to employer-sponsored insurance. The combination of poor insurance coverage, language barriers, and other factors contributes to reduced access to medical care services for immigrant children. This article reviews the literature, examines some common misconceptions regarding immigrants and the nation's health care problems, and describes potential federal, state, and local policies that could improve or weaken children's access to insurance and health care.     

Racial and ethnic disparities in access to care for children with special health care needs.

OBJECTIVE: Numerous studies have examined racial and ethnic differences in access to and utilization of health services. However, few studies have addressed these issues with respect to children with special health care needs. This study examines whether disparities in access and utilization are present among black, white, and Hispanic children identified as having special health care needs. METHODS: We analyzed data on 57 553 children younger than 18 years old included in the 1994-95 National Health Interview Survey on Disability. Of these, 10 169, or 17.7% of the sample, were identified as having an existing special health care need. Bivariate and multivariate analyses were used to assess how race and ethnicity are related to measures of access and utilization, such as usual source of care, missed care, and use of physician and hospital services. RESULTS: Our analyses show that among children with special health care needs, minorities were more likely than white children to be without health insurance coverage (13.2% vs 10.3%; P <.01), to be without usual source of care (6.7% vs 4.3%; P <.01), and to report inability to get needed medical care (3.9% vs 2.8%; P <.05). Also, white children with special health care needs were more likely than their minority counterparts to have used physician services (88.6 vs 85.0; P <.01); however, minority children with special health care needs were more likely to have been hospitalized during the past year (7.6% vs 6.3%; P < 0.5). After adjustments for confounding variables (income, insurance coverage, health status, and other variables), racial and ethnic differences in access and utilization were attenuated but remained significant for several measures (without a usual source of care, receipt of care outside of a doctor's office or HMO, no regular clinician, no doctor contacts in past year, and volume of doctor contacts). Gaps in access were more frequent and generally larger for Hispanic children with special health care needs. CONCLUSIONS: Our analysis indicates that access and utilization disparities remain between white and minority children with special health care needs, with Hispanic children experiencing especially disparate care.     

Rights of children and young people in health care

The 30th anniversary of the United Nations Convention on the Rights of the Child has provided opportunities for reflection, critical analysis and renewed commitment. While the convention is comprehensive and far reaching, the focus here is specifically on the rights of children in health care, with particular emphasis on the Australian setting. Surveys and related studies have highlighted persistent gaps and inadequacies in these domains of practice and especially in the direct and meaningful engagement of children and young people. The implementation of article 12 of the convention, the right of children to be heard and taken seriously, has been identified as a distinctly confronting challenge and the subject of improvement initiatives across, as well as beyond, health services. Appropriate reforms can only be progressed and sustained within a broader policy context that places children first and foremost, values their participatory engagement and embraces the crucial contribution of children's health and wellbeing to the future of our society.     

Unmet mental health need and access to services for children with special health care needs and their families.

OBJECTIVES: Studies suggest that children with disabilities or serious health conditions are vulnerable to mental health problems due to adjustment and limitation problems. The aim of this study was to examine rates and predictors of unmet mental health need among children with special health care needs (CSHCN) and their family members and to determine if race/ethnicity and language are associated with unmet need for the child and family members who have a mental health need attributed to the child's special needs. METHODS: Data are from the 2001 National Survey of Children with Special Health Care Needs, a nationally representative sample of CSHCN. RESULTS: Rates of unmet need were higher for CSHCN and family members of CSHCN with a chronic emotional, behavioral, or developmental problem (EBDP) compared to CSHCN with a mental health need but not a chronic EBDP. In multivariate analysis controlling for condition impact and demographics, among CSHCN with a chronic EBDP, African-American children had greater odds of unmet need (OR 1.60, 95% CI, 1.12-2.28), and family members of Hispanic children with a Spanish language parent interview had greater odds of unmet need compared to others (OR 4.48, 95% CI, 1.72-11.63). Lacking a personal doctor or nurse was associated with higher odds of unmet need for CSHCN with and without a chronic EBDP. CONCLUSION: Parents reported prevalent mental health needs of CSHCN as well as family members. Given the importance of family members to the care of CSHCN, research on racial/ethnic disparities in access to perceived needs should focus on children and their family members.     

Filling the GAPS: description and evaluation of a primary care intervention for children with chronic health conditions.

OBJECTIVES: Consistent with the "medical home" model, the GAPS program was developed to provide expanded care for children with a range of chronic health conditions within the context of primary care pediatric offices. Parents, pediatricians, and representatives from local Title V agencies participated to assess the child's and family's needs and to identify ways of addressing them. METHODS: Eleven pediatricians in 5 pediatric practices participated in the 4 main activities of the GAPS project: a) needs assessment; b) planning meeting among parents and pediatricians; c) practice-based advisory group; and d) Department of Public Health consultation. A telephone interview of parents and 2 needs assessment questionnaires completed by families were the 2 evaluation methods used. RESULTS: Parents were able to meet desires for "information" and "specific help." Moderate amounts of success were reported for meeting "contact" and "counseling" needs. Parents' explanations of unmet needs included lack of follow-through in obtaining services, unavailability of services, change of mind regarding needs, and pragmatic barriers. Socioeconomic status, the diagnosis and severity of the child's condition, and maternal psychological status were not significant predictors of success in families' ability to get their needs met. CONCLUSIONS: Active collaboration among parents, pediatricians, and Department of Public Health staff helps to ensure comprehensive coordinated care for families of children with chronic health conditions. Considerable challenges remain in implementing effective medical homes.     

Developmental surveillance of infants and young children in pediatric primary care

PURPOSE OF REVIEW: This article reviews the importance of appropriate developmental surveillance in early childhood, what is known about its effectiveness in current pediatric practice, and ways in which its delivery can be improved to optimize child outcomes. RECENT FINDINGS: Many infants and young children with developmental delays or risk factors for poor developmental outcomes are not identified by pediatric practitioners in a timely manner. When they are identified, they are often not referred to appropriate early intervention services or early childhood development programs. They are therefore denied the opportunity to benefit from programs documented to have long-lasting benefits for children. Structuring developmental screening around the use of validated parent questionnaires improves the rates at which children with developmental needs are appropriately identified. At the same time, lowering thresholds for referral improves the rates at which children with identified needs receive appropriate services. SUMMARY: Pediatric practitioners are uniquely positioned to improve children's developmental outcomes through early identification and referral of children with developmental delays or risk factors for poor developmental outcomes. Unfortunately, inappropriate screening practices, high thresholds for referral, misplaced concerns about causing parental anxiety, and unfamiliarity with local resources all diminish the effectiveness with which many practitioners conduct developmental surveillance. Recent studies show that small changes in screening and referral practices have the potential to greatly improve the effectiveness of developmental surveillance. This, in turn, has the potential to improve lifelong outcomes for children.     

Overweight among young children in the Philadelphia health care centers: incidence and prevalence

OBJECTIVES: To estimate the prevalence and incidence of overweight among low-income, inner-city children aged 3 to 7 years and to determine predictors of changes in body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) percentile. DESIGN: Retrospective cohort study using administrative and medical records. SETTING: The Philadelphia Health Care Centers, 1996 through 2003. PARTICIPANTS: Three hundred eighty-six patients who had at least 2 well-child visits between the ages of 3 and 7 years, had at least 1 visit between September 2001 and 2003, and were between the ages of 5 and 7 years at the most recent visit. Mean follow-up time was 2.4 years. MAIN EXPOSURES: Age, sex, race/ethnicity, and BMI percentile at baseline. MAIN OUTCOME MEASURES: Prevalence and incidence of overweight and at risk of overweight and change in BMI percentile. RESULTS: Prevalence of overweight at the initial visit was 18%, with 16% at risk of overweight. At the last visit, the prevalence of overweight was 19%, with 15% at risk of overweight. Based on maximum BMI percentile, 29% were overweight at some point and an additional 19% were at risk of overweight at least once. Annualized incidence of overweight among those not overweight at baseline was 5% per year: 2% per year for normal-weight children and 14% per year for children in the at-risk category. The outcomes were not associated with sex, race/ethnicity, or age at first or last visit. Incident overweight was positively associated with BMI percentile at baseline. CONCLUSION: The early onset and frequent persistence of overweight demonstrated herein underline the need to prevent overweight among very young children.     

An issue of access: delivering equitable health care for newly arrived refugee children in Australia

Newly arrived refugees and asylum seekers are faced with many difficulties in accessing effective health care when settling in Australia. Cultural, language and financial constraints, lack of awareness of available services, and lack of health provider understanding of the complex health concerns of refugees can all contribute to limiting access to health care. Understanding the complexities of a new health care system under these circumstances and finding a regular health provider may be difficult. In some cases there may be a fundamental distrust of government services. The different levels of health entitlements by visa category and (for some) detention on arrival in Australia may further complicate the provision and use of health services for providers and patients. Children are particularly at risk of suboptimal health care due to the impact of these factors combined with the effect of resettlement stresses on parents' ability to care for their children. Unaccompanied and separated children, and those in detention experience additional challenges in accessing care. This article aims to increase awareness among health professionals caring for refugee children of the challenges faced by this group in accessing and receiving effective health care in Australia. Particular consideration is given to the issues of equity, rights of asylum seekers, communication and cultural sensitivities in health care provision, and addressing barriers to health care. The aim of the paper is to alert practitioners to the complex issues surrounding the delivery of health care to refugee children and provide realistic recommendations to guide practice.