Mothers' health beliefs and children's clinic visits

This paper reports results from a prospective study of the relationship between mothers' health attitudes and beliefs and their utilization of pediatric clinic services for their children. Attitudinal data were obtained in interviews with a random sample of mothers attending the Children and Youth clinic of a large teaching hospital; data about children's clinic visits during a period of 3 1/2 years subsequent to the interview were abstracted from their medical records. Four aspects of clinic utilization were examined: visits for well-child care; acute-illness visits; accident-related visits; and appointment keeping. Health attitudes were found to be associated with both preventive and illness/accident visits, but in opposite directions. Mothers with an active, interventionist orientation towards health care and mothers who attributed good health and low illness-susceptibility to their children were high users of preventive services and generated few illness/accident visits. Conversely, more passive mothers, and mothers who perceived their children to be in poor health and susceptible to illness, were responsible for fewer well-child and more illness/accident visits. Mothers' agreement with the physician's diagnosis at the index visit was an additional strong predictor of use of well-child services, while disagreement was associated with more visits for illness and accidents. The convenience of appointment times and general satisfaction with the clinic were the best predictors of appointment keeping.These results indicate the importance of distinguishing between different dimensions of health care utilization in studies that attempt to account for this behavior; they also suggest that modification of health attitudes may prove to be an effective way to bring about positive changes in patterns of health services use.Drs. Becker and Kirscht are Professors, Department of Health Behavior and Health Education, School of Public Health, The University of Michigan, 1420 Washington Heights, Ann Arbor, Michigan 48109; Dr. Nathanson is Associate Professor, Department of Population Dynamics, School of Hygiene and Public Health, and Dr. Drachman is Associate Professor, School of Medicine, The Johns Hopkins University, Baltimore, Maryland. This research was supported by grant HD-00061 from the National Institute of Child Health and Human Development.     

Factors Related to Receipt of Well-Child Visits in Insured Children

Our objective was to identify factors related to receipt of the recommended number of well-child visits in insured children. We hypothesized parent insurance status would be related to receipt of well-child visits, with those with uninsured parents more likely to have fewer visits than recommended. Data for the study came from the 2007 Medical Expenditure Panel Survey-Household Component. The sample included children <18 years of age with full-year insurance coverage and parents who were insured or uninsured the entire year. The outcome variable indicated whether children had received fewer than the recommended number of well-child visits in physician offices or outpatient departments. Parent, family, and child characteristics were measured. Forty-eight percent of the 4,650 children included in the study had fewer well-child visits than recommended. Children whose parents did not visit a physician during the year and children whose parents had not completed high school were more likely to miss recommended visits. Parent insurance status did not affect well-child visits. We identified child, family, and parent factors influencing well-child visits in insured children, including the parent’s own use of physician visits. Contrary to our hypothesis, well-child visits were not influenced by parent insurance status. Determining which insured children are at greater risk of missing recommended well-child visits aids policymakers in identifying those who may benefit from interventions to improve use of preventive care.     

Early detection of parenting and developmental problems in toddlers: A randomized trial of home visits versus well-baby clinic visits in the Netherlands

ObjectiveThe early detection of parenting and developmental problems by preventive child health care (CHC) services in the Netherlands takes place almost exclusively at the well-baby clinic. This study assesses whether, compared to a visit to the well-baby clinic, a home visit improves early detection.Methods4481 eligible 18-month-old children and their parents were randomized to either a visit to the well-baby clinic or a home visit in the period from December 2006 to January 2008. A CHC nurse held structured interviews using the validated Structured Problem Analysis of Raising Kids (SPARK). Differences in the percentage of children with high or increased risks of parenting and developmental problems as assessed by the SPARK were analyzed with ordinal regression. Secondary outcomes included the percentage of parents attending, parents' concerns, needs assessment by parents and CHC professionals and user experience.ResultsResponse rates were 94.0% for the home visit group and 93.2% for the well-baby clinic group. Using the SPARK at home identified significantly more high-risk children compared to clinic visits (3.7 vs. 2.6%) and fewer children with increased risk (19.1 vs. 20.7%; overall p = 0.028). Home visits more often involved both parents and other children. At home, parents reported more concerns. Both parents and CHC nurses more often expressed the need for support and reported significantly better experiences at home.ConclusionsAided by a validated structured interview, CHC professionals detect more children with high risks of parenting and child-developmental problems during home visits than during clinic visits.Clinical Trial Registration: www.trialregister.nl Identifier: NTR1413     

Correlates of Physician Visits Among Children and Adolescents in West Texas: Effects Of Hyperglycemia Symptoms

CONTEXT: Health care services use by children varies tremendously. Because of the increasing prevalence of diabetes in children and adolscents, one of the major concerns is access to physician care among children with diabetes and diabetes symptoms. PURPOSE: This population-based cross-sectional study examines correlates of physician visit among children and adolescents living in west Texas. METHODS: A telephone survey was administered in 2002 to a random sample of households in 106 counties of West Texas. The sample included 5,462 respondents with children aged between 3 and 18 years. Proportional odds ordered logistic regression analysis was used to determine correlates of physician visits in the previous 12 months. FINDINGS: Hispanic children were less likely than non-Hispanic whites to have a recent physician visit; there were no significant rural-urban differences. Children with insurance (adjusted odds ratio= 2.21, 95% CI = 1.89-2.59) were more likely to visit physicians. Almost 16% of children in this study did not have any health insurance coverage. Children reporting 3 or more hyperglycemia symptoms and those with a family history of diabetes had 1.81 times and 1.20 times the odds of visiting the physician. CONCLUSIONS: Presence of health insurance and increasing symptoms of diabetes were found to influence the utilization of physician services. Since most of the cases of diabetes that have recently been diagnosed among Texas youth are type 2 diabetes, it is important that adolescents and their parents are educated about the risk factors and how to recognize them.     

Paediatricians' attitudes about discussing maternal depression during a paediatric primary care visit

OBJECTIVES: To assess paediatricians' beliefs about discussing maternal depressive symptoms during a paediatric visit, and methods paediatricians use to identify mothers with depressive symptoms. METHODS: In-depth telephone interviews were conducted with 23 primary care paediatricians from a practice-based research network. We asked a series of previously developed questions about discussing maternal depressive symptoms during a paediatric visit; methods used to identify mothers at risk; barriers encountered, and potential strategies to improve recognition and treatment of maternal depression. Interviews were audiotaped and transcribed. Data were codified and analysed using standard qualitative data techniques. RESULTS: All paediatricians agreed that it is appropriate to ask mothers about their own health during a well-child visit, because a mother's well-being affects her children. Paediatricians relied on observational cues to identify a mother with depressive symptoms, especially mother-child interactions. Few used direct questions or a checklist. Almost all paediatricians felt that lack of time was the barrier most often faced in addressing maternal depression. Lack of training, inadequate knowledge of resources and distractions encountered in the primary care setting were additional barriers cited. One-third of paediatricians acknowledged the fear of judgement and stigma that a mother may face when discussing maternal stresses. Paediatricians desired better ability to refer mothers to social workers for help. CONCLUSIONS: Observational cues are used more often than direct questions or screening tools to identify mothers at risk of depression. This may under-identify mothers at risk. Paediatricians prefer to rely on other professionals, particularly social services, to address maternal depression, yet mothers may be hesitant or ambivalent about such assistance because of fear of judgement. Paediatricians, in fact, may be the professional mothers most want to communicate with. Thus, appreciation of mothers' perspectives, empathetic communication skills and knowledge of community resources can enhance paediatricians' abilities to assist mothers at risk for depression.     

The Relationships Among Maternal Health Locus of Control Beliefs and Expectations,Pediatrician-Mother Communication,and Maternal Satisfaction With Well-Infant Care

The objective of this study was to assess the relationship among mothers' perceptions of control over the health of their children, mothers' expectations about and satisfaction with their infants' pediatric well-child care visit, and selected attributes of pediatrician-mother interaction during these well-care visits. Results suggest that pediatrician-mother interaction during well-child visits is responsive to mothers' locus of control beliefs with regard to their children's health and expectations regarding physician interactive behavior. Moreover, pediatrician-mother interaction was predictive of maternal overall satisfaction. These results are discussed both theoretically and within an applied perspective.     

Parental Depressive Symptoms and Children’s School Attendance and Emergency Department Use: A Nationally Representative Study

We sought to assess the association between parental depressive symptoms and school attendance and emergency department (ED) use among children with and without chronic health conditions. Secondary analysis of the 1997–2004 National Health Interview Survey, a nationally representative survey. Parental depressive symptoms were measured by three questions assessing sadness, hopelessness, or worthlessness in the past month. Children with and without asthma or attention-deficit/hyperactivity disorder (ADHD) were identified, and their school attendance and ED visits were reported by adult household respondents. Children with information on parental depressive symptoms, health conditions, and services use were eligible. We incorporated weights available in the survey for each eligible child to reflect the complex sampling design. 104,930 eligible children were identified. The point prevalence of parental depressive symptoms was low (1.8 %, 95 % CI 1.7–2.0), but greater among children with asthma (2.7 %, 95 % CI 2.4–3.0) and ADHD (3.8 %, 95 % CI 3.2–4.4) than among other children (1.6 %, 95 % CI 1.5–1.7). After adjustment for potential confounders, children whose parents reported depressive symptoms most or all of the time were more likely to report an ED visit (adjusted incident rate ratio [IRR] 1.18, 95 % CI 1.06–1.32) or school absence (adjusted IRR 1.36, 95 % CI 1.14–1.63) than children whose parents did not. The effect of parental depressive symptoms was not modified by child health conditions. Parental depressive symptoms were adversely associated with school attendance and ED use in children. These results suggest the importance of measuring depressive symptoms among adult caregivers of children.     

Parental mental and pain-related health and pediatric ambulatory care sensitive emergency department visits and hospitalizations

OBJECTIVE: To investigate the types of parental psychiatric and pain-related (PR) conditions that are associated with inadequate management of children's health and medical needs. DATA SOURCES: The 1997-1998 Thomson/Medstat MarketScan claims and administrative dataset. STUDY DESIGN: A cross-sectional study that assessed the associations between parents' claims for psychiatric and PR conditions, and their children's well-child care as well as emergency department (ED) visits and hospitalizations for conditions that can be treated effectively in outpatient settings (ambulatory care sensitive [ACS] conditions). DATA EXTRACTION METHODS: Claims were extracted for 258,313 children of ages 0-17 years and their parents, who had insurance coverage for a full 2-year period. PRINCIPLE FINDINGS: Multiple parental psychiatric and PR diagnoses were associated with child ACS emergency services/hospitalizations. Maternal depression was negatively associated with a child having the recommended well-child visits (odds ratio [OR]: 0.92, 95 percent confidence intervals [CI]: 0.84-0.99). The combined diagnoses of maternal depression and back pain was positively associated with a child having an ACS-ED visit (OR: 1.64, 95 percent CI: 1.33-2.03) and a child having an ACS hospitalization (OR: 2.04, 95 percent CI: 1.34-3.09). CONCLUSIONS: Pediatricians' ability to manage child health may be enhanced with coordinated management of parental psychopathology and PR health conditions.     

Text message reminders to improve infant immunization in Guatemala: A randomized clinical trial

ObjectiveMillions of infants worldwide remain under-immunized and at risk for unnecessary morbidity and mortality. Text messaging may offer a low-cost solution. We aimed to evaluate text message reminders to improve infant immunization in Guatemala.MethodsA randomized clinical trial was conducted at four public health clinics in rural and urban Guatemala. Infants ages six weeks to six months presenting for the first visit of the primary immunization series were randomly and equally allocated to an intervention or usual care group. Intervention participants were sent three text reminders before the second and third vaccine visits. The main outcome was timeliness of the second and third visits of the primary immunization series.ResultsOf 1088 families approached for enrollment between March to November 2016, 871 were eligible and 720 (82.7%) participated; only 54 families did not own a cell phone. Due to country-wide vaccine shortages, visit completion was used as a proxy for overall immunization coverage. In intention to treat analysis, both intervention and usual care groups had high rates of visit completion, but intervention participants presented on the scheduled date more often (151 [42.2%] of 358 intervention vs. 111 [30.7%] of 362 usual care participants for visit 2, p = 0.001, and 112 [34.0%] of 329 intervention vs. 90 [27.0%] of 333 usual care participants for visit 3, p = 0.05). Intervention caregivers were significantly more likely to want to receive future text message reminders for vaccines and other appointments and were more willing to pay for these reminders.ConclusionCaregivers who were sent text message reminders in urban and rural Guatemala were less delayed for their child’s immunization visits and reported high user satisfaction. Text message reminders may be an effective tool to increase infant vaccination coverage in low-income settings by reminding parents to vaccinate.Trial Registration: NCT02567006 at clinicaltrials.gov.     

Reducing the exposure of children to environmental tobacco smoke. An office-based intervention program

It is important for the family physician to consider a spectrum of screening tests, counseling topics, and childhood immunizations when providing acute and chronic care, in addition to well-child care. The effectiveness of specific clinical preventive services in eliciting positive health outcomes and age-related guidelines to prioritize health promotion activity have recently been reviewed by the US Preventive Services Task Force. Given recent studies identifying environmental tobacco smoke as a risk factor for children by being associated with an increase in the incidence and severity of respiratory tract and ear infections, family physicians should be routinely screening parents, especially during visits that provide teachable moments for counseling and intervention. Family physicians need to be aware of possible responses parents may have to their counseling and provide nonjudgmental information and guidance throughout a child's early years of development.     

How do family physicians provide anticipatory guidance during well-child visits?

INTRODUCTION: Anticipatory guidance is an important part of well-child care, yet little is known about the way family physicians provide this guidance. This study describes the methods that family physicians use to provide anticipatory guidance during well-child visits. METHODS: A questionnaire was mailed to 1000 family physicians. Respondents rated 6 anticipatory guidance methods on frequency of use. The questionnaire addressed method of documentation, use of forms or guidance prompts, visit frequency for total, well-child, and other pediatric visits, and demographic information; t tests and ANOVA were applied (P < .05 significant). RESULTS: There were 495 questionnaires returned for a response rate of 49.5%. Respondents were more likely to provide anticipatory guidance verbally than by handout (Likert scale where 1 = never and 9 = always, mean 7.8 vs 4.2, P < .0001). Physicians using well visit forms more commonly initiate guidance discussions (7.6 vs 6.8, P = .0002), address concerns (8.2 vs 7.5, P = .0001), and provide handouts (4.3 vs 3.3, P = .0002). Physicians in academic or multispecialty practices used handouts more often than private practitioners (5.0 vs 3.6, P = .0003, 5.1 vs 3.6, P = .0002, respectively) as did those with > or = 7 well-child visits per week compared with < 7 visits per week (4.8 vs 3.8, P = .0028). CONCLUSIONS: Family physicians primarily provide anticipatory guidance verbally. Use of well visit forms or other prompts are associated with better provision of anticipatory guidance.     

Effectiveness of telephone reminders in improving rate of appointments kept at an outpatient clinic: a randomized controlled trial

BACKGROUND: Clinic appointments in which patients do not appear (no-show) result in loss of provider time and revenue. Previous studies have shown variable effectiveness in telephone and mailed reminders to patients. METHODS: We conducted a randomized controlled trial of telephone reminders 1 day before the scheduled appointments in an urban family practice residency clinic. Patients with appointments were randomized to be telephoned 1 day before the scheduled visit; 479 patients were telephoned and 424 patients were not telephoned. RESULTS: The proportions of patients not showing up for their appointments were 19% in the telephoned and 26% in the not-telephoned groups (P = .0065). Significantly more cancelations were made when telephoning patients before their visit, 17% compared with 9.9%. The opened scheduling slots were used for appointments for other patients. This additional revenue offset the cost of telephone intervention in our cost analysis. CONCLUSION: Reminding patients by telephone calls 1 day before their appointments yields increased cancelations that can be used to schedule other patients. Telephone reminders provide substantial net revenue, but the results may be population specific.     

Text message reminders for timely routine MMR vaccination: A randomized controlled trial

ObjectiveMeasles–mumps–rubella (MMR) vaccination is important for preventing disease outbreaks, yet pockets of under-vaccination persist. Text message reminders have been employed successfully for other pediatric vaccines, but studies examining their use for MMR vaccination are limited. This study assessed the impact of text message reminders on timely MMR vaccination.Study designParents (n = 2054) of 9.5–10.5-month-old children from four urban academically-affiliated pediatric clinics were randomized to scheduling plus appointment text message reminders, appointment text message reminder-only, or usual care. The former included up to three text reminders to schedule the one-year preventive care visit. Both text messaging arms included a text reminder sent 2 days before that visit. Outcomes included appointment scheduling, appointment attendance, and MMR vaccination by age 13 months, the standard of care at study sites.ResultsChildren of parents in the scheduling plus appointment text message reminders arm were more likely to have a scheduled one-year visit than those in the other arms (71.9% vs. 67.4%, relative risk ratio (RRR) 1.07 [95% CI 1.005–1.13]), particularly if no appointment was scheduled before randomization (i.e., no baseline appointment) (62.1% vs. 54.7%, RRR 1.14 [95% CI 1.04–1.24]). One-year visit attendance and timely MMR vaccination were similar between arms. However, among children without a baseline appointment, those with parents in the scheduling plus appointment text message reminders arm were more likely to undergo timely MMR vaccination (61.1% vs. 55.1%, RRR 1.11 [95% CI 1.01–1.21]).ConclusionText message reminders improved timely MMR vaccination of high-risk children without a baseline one-year visit.     

Patient satisfaction with nurse-led telephone follow-up in women with lower urinary tract symptoms

We assessed the clinical effectiveness and patient satisfaction with nurse-led telephone follow-up of women with lower urinary tract symptoms. Participants were offered telephone follow-up with a nurse instead of a conventional outpatient appointment. Suitability was decided by the doctor who saw the women at her last visit. The consultation was conducted using the same principles as a routine clinic visit. Patient satisfaction was evaluated by postal questionnaire and they were also sent a standard urinary continence questionnaire, the Kings Health Questionnaire (KHQ), to evaluate their current symptoms. In total, 116 women were included. The mean number of telephone consultations was 2 (range 1-12). The mean overall satisfaction score was 77 (maximum 100, where a higher score indicates greater satisfaction). Only 16 patients (17%) did not prefer telephone follow-up to a clinic visit. Women who had been discharged via the telephone follow-up clinic expressed similar mean satisfaction scores to those whose next visit was a clinic visit (80 and 82, respectively). The KHQ also indicated that the patients had been appropriately discharged or given a further follow-up appointment. Nurse-led telephone follow-up is associated with high satisfaction and has the advantages of consistent follow-up by the same clinician, convenience to the patient and cost-savings.     

A randomized intervention study of sun protection promotion in well-child care

BACKGROUND: This study evaluated the behavioral impact of a skin cancer prevention program in which health care providers delivered advice and materials to parents of infants over a 3-year period from 1998 to 2001. METHODS: Fourteen offices of a large managed care organization in Colorado were randomly assigned to the intervention or control groups. 728 infants and their parents were recruited within 6 months of birth. At intervention offices, health care providers attended orientation sessions, prompts for delivering sun protection advice were placed in medical records, and parents received sun protection packets at each well-child visit between 2 and 36 months of age. RESULTS: Based on provider self-report and exit interviews of parents, providers in the intervention group delivered approximately twice as much sun protection advice as providers in the control group. Annual telephone interviews of parents indicated small but statistically significant differences in parent sun protection practices favoring the intervention. Skin exams revealed no significant differences in tanning, freckling, or number of nevi. Behavioral differences between groups appeared to grow over the 3 years of follow-up. CONCLUSIONS: This intervention strategy was successful in increasing the delivery of sun protection advice by health care providers and resulted in changes in parents' behaviors. While the behavioral effect was probably not strong enough to reduce risk for skin cancer, the effect may increase as children age and have more opportunities for overexposure to the sun.     

Brighter Smiles: Service learning, inter-professional collaboration and health promotion in a First Nations community

OBJECTIVE: The goal of Brighter Smiles was to improve children's dental health in a remote First Nations community in British Columbia in the context of a service-learning experience for pediatrics residents. SETTING AND PARTICIPANTS: The provincial Ministry of Health had competitive funds available for collaborations between remote communities and medical educators. Hartley Bay (Gitga'at), a tribe of the Tsimshian Nation, responded by declaring children's dental health to be a primary health concern. This northern community has an on-reserve population fluctuating around 200 people and is accessible only by air or water. INTERVENTION: A convenience sample of children had a baseline dental exam; parents also completed a questionnaire about dental health behaviours. Only 31% (4/13) of pre-kindergarten and 8% (2/26) of kindergarten to Grade 12 children had no dental caries. Planning of the Brighter Smiles intervention involved community leaders, teachers, parents, Elders, health care staff, pediatrics residents, and dental and medical faculty from the University of British Columbia (UBC). Brighter Smiles includes school-based brush-ins, fluoride programs, classroom presentations, and regular visits by UBC pediatrics residents to Hartley Bay to provide well-child care that includes age-appropriate dental counselling to parents at the clinic visits. OUTCOMES: An early success indicator was a significantly increased proportion of dental service provider's time scheduled for preventive maintenance services rather than dental rehabilitation (restorations and extractions). CONCLUSIONS: The goal of providing a service-learning experience for trainee pediatricians in a remote community has been achieved. In addition, early indicators demonstrate improvements in child oral health.     

Are Adolescents Being Screened for Emotional Distress in Primary Care?

PurposeTo assess primary care providers’ rates of screening for emotional distress among adolescent patients.MethodsSecondary data analysis utilizing data from: (1) well visits in pediatric clinics within a managed care plan in California, and (2) the 2003 California Health Interview Survey (CHIS), a state population sample. The Pediatric clinic sample included 1089 adolescent patients, ages 13 to 17, who completed a survey about provider screening immediately upon exiting a well visit. The CHIS sample included 899 adolescents, ages 13 to 17, who had a routine physical exam within the past 3 months. As part of the survey, adolescents answered a question about whether they had talked with their provider about their emotions at the time of the exam. Logistic regressions, controlling for age, gender, race/ethnicity, and adolescent depressive symptoms were performed.ResultsAbout one-third of adolescents reported a discussion of emotional health. Females were significantly more likely to be screened than males (36% vs. 30% in clinic; 37% vs. 26% in CHIS); as were older and Latino adolescents in the clinic sample. Although 27% of teens endorsed emotional distress, distress was not a significant predictor of talking to a provider about emotions.ConclusionsPrimary care clinicians/systems need to better utilize the primary care visit to screen adolescents for emotional health.     

An epidemiological study of consultations of children under 5 years of age in Brazzaville (Congo)

In most of the large cities in developing countries, geographic accessibility to health care is not a major problem. Thus, indifference to public services and a preference for home treatment, recourse to traditional medicine or to the private sector may be related to problems in the quality of services. A cross-sectional epidemiological study of hospital visits by under-5 children was carried out in health centres and hospital out-patient services in Brazzaville (Congo). Sampling in these health facilities was done using a systematic random sample with a proportion of 25%, during 4 periods chosen according to seasonal factors. An exhaustive investigation of the entire public sector serving children was done in the study. At the same time, the same data were gathered in a sample of private facilities (doctors' and nurses' offices, traditional healers, religious healing centres), chosen as a function of their permanence and the numbers of their clientele. This article analyses services offered during 2215 visits by children, who were under 1 year of age in more than 50% of cases. In the public sector, 75% of visits were to first-line health centres. Public services show marked dysfunctions: the complexity of internal referrals, clinical examinations which are inadequate in relation to symptoms, and poor communication (explanations as to cause of illness in less than 2% of cases, and on treatments in less than 50% of cases). Communication seems well developed among private physicians and traditional healers, the latter engaging in both preventive and curative activities. Communication during well-child visits and consultations at health centres is especially disappointing, in light of the very young age of the parents (1/4 are high-school or college students). There is a two-fold risk in this situation: flight towards non-conventional medicine on the one hand, and access to private medicine based on socio-economic status on the other. It thus appears necessary to standardise procedures and acts in first line public health services and to promote training of personnel in communication skills with families (training using social science perspectives and participative pedagogical techniques).     

Evaluation of a follow-up system in a county health department's immunization clinic

We designed a pilot follow-up system using two mailed reminders and evaluated it for use in the immunization clinic of a relatively large county health department in Washington State. Compliance with the recommended interval for DTP immunizations increased by 33.9% in the group of children receiving two postcard reminders compared to the control group. Over half of the respondents (52%) in the control group and 28% in the intervention group reported that transportation barriers and clinic problems prevented their return.