Preparing Child Care Health Consultants to Address Childhood Overweight: A Randomized Controlled Trial Comparing Web to In-Person Training

Objectives Child care centers have recently become targets for overweight prevention efforts directed at young children. Child Care Health Consultants (CCHCs), who provide consultation to these centers, receive little training on the basic nutrition and physical activity principles important for the promotion of child healthy weight. Traditional approaches, such as in-person training, are limited in their ability to disseminate health information to a geographically diverse population of health professionals. The purpose of this study was to determine if web-based training is as effective as in-person training. Methods A randomized controlled trial was conducted between August 2005 and June 2006 with 50 CCHCs. Web-based and in-person trained CCHCs were compared to each other and to controls. The main outcome of this study was performance on a test of nutrition knowledge related to childhood overweight measured by a 28-item multiple choice test administered pre- and post-training. Results Results from the ANCOVA model suggest that web trained CCHCs performed similarly to in-person trained CCHCs on the knowledge test (P < .0001). Additionally, both training groups improved significantly compared to controls (P < .0001 for each group). Conclusions This study found no significant differences in post-training knowledge between in-person and web trained Child Care Health Consultants. Scores on the post-training knowledge test were within 0.5 points for the in-person and web trained groups. These results demonstrate that web-based instruction is as effective as in-person training on improving basic nutrition and physical activity knowledge for promoting healthy weight in preschool children.     

Assessing Indiana’s Health and Safety in Early Care and Education Programs: Identifying Areas for Improvement

The objective of this study is to describe the key National Health and Safety Standards (NHS) met in early care and education (ECE) programs in Indiana and to establish reliability for the Indiana Health and Safety Checklist. The Indiana Health and Safety Checklist, modified from the California Childcare Health Program’s Health and Safety Checklist, includes 87 items and 11 subscales. It was completed in 2 h by trained child care health consultants in 82 ECE programs to assess the number of key NHS met. The 82 ECE programs met the majority of NHS items. Thirteen items were not met in more than 50% of the programs. The items with the lowest compliance were emergency food supplies, children’s hand washing, special health care plans, cleaning and sanitizing counters, and impact surfaces under playground equipment. The Indiana Health and Safety Checklist had moderate internal reliability for 6 of the 9 subscales analyzed. ECE programs strive to provide high quality care and the programs met the majority of NHS on the checklist. The Checklist is a reliable instrument that helped identify health and safety gaps and thus, identified the targeted interventions for child care health consultation.     

Integrating Children's Health Services: Evaluation of a National Demonstration Project

Objectives: Increasingly, the public and private sectors are turning to service integration efforts to reduce, if not eliminate, barriers to needed care created by categorical programs. In 1991, the Robert Wood Johnson Foundation established a new national demonstration project, called the Child Health Initiative, intended to test the feasibility of developing mechanisms at the community level to coordinate the delivery of health services and to pay for those services through a flexible pool of previously categorical funds. This article presents the findings of an independent evaluation of the Child Health Initiative. Method: The evaluation utilized a combination of qualitative methods to assess and describe the experiences of the communities as they developed and implemented integrated health services. It used a repeated measures design involving two site visits and interim telephone interviews, as well as review of documents. Results: Overall, the demonstration project achieved mixed success. Both care coordination and the production of community health report cards were found to be achievable within the relatively short life of the foundation grant. However, many sites experienced significant delays in the production of report cards and implementing care coordination plans because the sites largely did not benefit from the successful models already in existence. Little clear progress was made in implementing the decategorization component of the project. Sites experienced difficulties due to lack of previous experience with this new undertaking, the inability to secure active cooperation from local, state, and federal agencies, the relatively short duration of the project, and other factors. Conclusions: A number of lessons were learned from this project that may be useful in future decategorization experiments, including (1) a clear understanding of the concept and its applications among all parties is essential, (2) high-level political commitments to the effort are needed between all levels of government, (3) adequate technical assistance should be provided to surmount technical considerations in establishing a workable approach to decategorization, and (4) decategorization and service integration efforts should focus on both the health and social sectors.     

农村儿童保健系统管理和预防接种情况调查

目的:了解农村地区儿童保健系统管理和预防接种情况,找出存在的问题,提出改进措施。方法:采取多阶段分层随机抽样方法,通过自行设计的儿童系统管理保健情况和预防接种情况调查表对抽取的样本户入户进行定量调查。结果:97.8%的产后访视工作由村卫生室和乡镇卫生院进行,受访儿童建卡率100.0%,所有儿童家长均对儿童保健服务表示满意。绝大部分儿童按时接种疫苗,95.5%的儿童在乡镇卫生院/社区卫生服务中心接种,卫生机构和儿童家长均认为较好的通知接种方式是预约和发送通知单。结论:调查地区儿童保健管理工作较系统和全面,预防接种工作开展较好,但仍需提高乡、村两级医疗机构的应急反应能力和医疗水平。     

Partnership to build sustainable public health nurse child care health support

Child care health consultation, an emerging health care delivery system aimed at improving the health and well-being of children enrolled in child care settings, is consistent with the public health core function of assurance. Public health nurses are the primary workforce for such consultation. Few states have critical masses of consultants, and many are struggling to financially support such programs. Through an academic-community partnership, Georgia's public health nurses are building a consultative system of child care health support. This partnership focuses on adding value in child care while strategically and financially supporting the sustainability of this population-focused practice.     

Overcoming the Odds: Access to Care for Immigrant Children in Working Poor Families in California

Objectives: To explore the extent to which, among working poor families, uninsured immigrant children experience more barriers to care than uninsured nonimmigrants, and compare these differences to those of insured children. Methods: We used data from the 2001 California Health Interview Survey, a randomized, population-based telephone survey conducted from November 2000 through September 2001. Financial and nonfinancial access to health care and utilization of health services were examined for 3,978 nonimmigrant and 462 immigrant children and adolescents under the age of 18 years. We compared differences in crude rates across four subgroups (insured immigrants, uninsured immigrants, insured nonimmigrants, uninsured nonimmigrants) and in adjusted models controlling for socioeconomic and immigration characteristics, parental language, health status, and other demographic factors. Results: More immigrant than nonimmigrant children lacked health insurance at the time of the interview (44% vs. 17%, p < 0.0001). Among the uninsured, immigrants had higher odds of perceiving discrimination (11% vs. 5%, p < 0.05) and postponing emergency room (ER) (16% vs. 7%, p < 0.05) and dental care (40% vs. 30%, p < 0.05) after controlling for covariates. Among the insured, immigrants fared worse on almost every access and utilization outcome. Among insured immigrants, child and parent undocumented status and having a non-English-speaking parent contributed to missed physician and ER visits. Conclusions: Disparities in access and use remain for immigrant poor children despite public insurance eligibility expansions. Insurance does not guarantee equitable health care access and use for undocumented children. Financial and nonfinancial barriers to health care for immigrant children must be removed if we are to address disparities among minority children.     

Changing Definitions of Women's Health: Implications for Health Care and Policy

Objectives: To present an overview of how and why normative conceptions of women's health are changing and to discuss some implications of definitional shifts in the context of the changing U.S. health care system. Method: The paper describes the historical development of views of women's health and health care, contrasts the biomedical and biopsychosocial perspectives on women's health, and presents some evidence of challenges and opportunities for change in health care and policy. Results: While women's health has generally been equated with reproductive functions, expanded definitions focus on health through the life span and in the context of women's multiple roles and diverse social circumstances. This expanded view highlights the limitations of health services and policy based on narrower conceptions and program mandates and the need for strategies for integrated, continuous care. There is evidence of change in women's health care, including in Title V programs. Conclusions: New understandings of women's health are particularly relevant to maternal and child health programs, which are positioned to provide model approaches for improving women's health care.     

‘Just doing the best we can’: health care providers’ perceptions of barriers to providing care to Marshallese patients in Arkansas

ABSTRACT

Introduction: Marshallese migrating to the United States encounter challenges in accessing health care. Previous literature has investigated Marshallese participants’ perceptions of the barriers they face in accessing health care. For this study, health care providers managing the care of Marshallese patients were interviewed to understand the providers’ perception of barriers that their Marshallese patients encounter.

Methods: A qualitative research design was utilized to explore health care providers’ perceptions of and experiences with the barriers faced by their Marshallese patients when accessing the US health care system.

Results: The primary barriers identified were: (1) economic barriers; (2) communication challenges; (3) difficulty understanding and navigating the western health care system; and (4) structural and system barriers.

Conclusion: This study provides insight on the barriers Marshallese patients face in accessing health care as well as the barriers providers face in delivering care to Marshallese patients. A better understanding of these barriers can help health care providers and educators to begin initiating improvements in the delivery of care to Marshallese patients.     

Disparities in primary care for vulnerable children: the influence of multiple risk factors

OBJECTIVES: To analyze vulnerability as a profile of multiple risk factors for poor pediatric care based on race/ethnicity, poverty status, parent education, insurance, and language. Profiles are used to examine disparities in child/adolescent health status and primary care experience. DATA SOURCES: Cross-sectional data on 19,485 children/adolescents 0-19 years of age from the 2001 California Health Interview Survey. STUDY DESIGN: Multiple logistic regression models are used to examine risk profiles in relation to health status and three aspects of primary care: access (physician and dental visit; access surety), continuity (regular source of care), and comprehensiveness (i.e., health promotion counseling). PRINCIPAL FINDINGS: About 43 percent of (or 4.4 million) children in California have two or more risk factors (RF). Controlling for age and gender, more RFs is associated with poorer health status (i.e. percent reporting "excellent/very good" health: no RFs=81 percent, 1=71 percent, 2=57 percent, 3=45 percent, 4=35 percent, 5=28 percent, all p<.001). Controlling for health status, higher risk profiles is associated with poorer primary care access and continuity, but greater comprehensiveness of care. For example, higher risk profile children are less likely to have a regular source of care: one RF (prevalence ratio [PR]=0.92, confidence interval [CI]: 0.86-0.98), two (PR=0.77, CI: 0.69-0.84), three (PR=0.55, CI: 0.46-0.65), and four or more (PR=0.31, CI: 0.22-0.44), all p<.001. CONCLUSIONS: This study demonstrates a dose-response relationship of higher risk profiles with poorer child health status, access to, and continuity of primary care. Having gained access, however, adolescents with higher risk profiles are more likely to receive health promotion counseling. Higher profiles appear to be associated with greater barriers to accessing primary care for children in "fair or poor" health, suggesting that vulnerable children who have the greatest health care needs also have the greatest difficulty obtaining primary care.     

State Policy Environment and Delayed or Forgone Care Among Children with Special Health Care Needs

Objective To evaluate if children with special health care needs (CSHCN) residing in states with more generous public insurance programs were less likely to report delayed or forgone care. Methods We used multilevel modeling to evaluate state policy characteristics after controlling for individual characteristics. We used the 2001 National Survey of CSHCN for individual-level data (N = 33,317) merged with state-level data, which included measures of the state’s public insurance programs (Medicaid eligibility and enrollment, spending on Medicaid, SCHIP and Title V, and income eligibility levels), state poverty level and provider supply (including pediatric primary care and specialty providers). We also included a variable for state waivers for CSHCN requiring institutional level care. Results Delayed or forgone care significantly varied among CSHCN between states, net of individual characteristics. Of all the state characteristics studied, only the Medicaid income eligibility levels influenced the risk of experiencing delayed care. CSHCN living in states with higher income eligibility thresholds or more generous eligibility levels were less likely to experience delayed care (OR 0.89(0.80,0.99); P ≤ 0.05). Conclusions By analyzing child health policy in the context of individual characteristics that may place a child at risk for delayed care, we determined that improving Medicaid eligibility levels improved the process of care for CSHCN.     

上海市徐汇区儿童保健服务现状和需求的定性调查

目的:了解徐汇区社区儿童保健现状与需求的差别,为明确今后的工作重点提供依据。方法:结合现有资料,采用定性研究方法中个人访谈和小组访谈的方式,对儿童保健服务的管理者和提供者进行深入访谈。结果:儿童心理行为问题比较突出;儿童家长对于育儿指导、早期教育的需求较大且尚未满足,微量元素的测定的需求尚能满足;对智力开发的需求过度;现有儿童保健服务项目可以适当调整。结论:儿童家长对保健服务的需求不断增加,服务提供者不仅要了解、满足儿童家长需求,也要引导正确的需求方向,提高儿童保健工作水平。     

Preventing Low Birth Weight in Illinois: Outcomes of the Family Case Management Program

Objectives: In the mid 1980's the federal government passed legislation allowing states to expand their Medicaid programs for pregnant women. States were also offered matching funds for “enhanced” prenatal care services. The Illinois Family Case Management (FCM) Program targets low-income women and aims to reduce barriers to prenatal care and infant healthcare utilization and also provides health education. We evaluated the outcome of the Illinois Family Case Management Program (FCM) in preventing low birth weight in Winnebago County. Methods: A total of 6,440 participants were included in this study. Logistic regression was used to test whether number of visits or total hours of visitation were significant protective factors against low birth weight. Results: While participating in the FCM Program resulted in a lower rate of low birth weight delivery, neither increasing time with a family case manager nor increasing number of visits showed statistically significant additional protection against low birth weight delivery after adjustment for potential confounding factors. Conclusion: In order to further improve program outcomes, efforts need to include improving quality of interventions or developing new interventions rather than simply increasing the amount of current intervention for each participant. The cost effectiveness of shifting FCM Program efforts away from infants (aged 0–1 year) towards improved prenatal interventions should be evaluated.Rodrigo Silva partially funded through a fellowship from CityMatCH, Omaha, Nebraska     

Parental Nativity Affects Children’s Health and Access to Care

Objective To examine the effect of parental nativity on child health and access to health care. Data Source The 2002 National Survey of America’s Families. Results Among US children, 14% have foreign-born parents; 5% have one foreign- and one native-born parent (“mixed-nativity”). In multivariate logistic regression analyses, children with foreign-born parents were less likely than children with US-born parents to be perceived in “very good” or “excellent health” [OR = 0.68; 95% CI (0.56–0.82)] and to have a usual health care site [OR = 0.52 (0.38–0.69)]; having mixed-nativity parents is associated with better perceived child health. These effects persisted for minority, but not white, children. Regardless of race and ethnicity, non-citizen children have worse access to care. Conclusion Efforts to improve children of immigrants’ health and access to care should focus on families in which both parents are immigrants, particularly those who are ethnic or racial minorities. Efforts to increase use of health services should focus on non-citizen children.     

Telepsychiatry Consultation for Primary Care Treatment of Children and Adolescents Receiving Child Protective Services in Chile: Mixed Methods Feasibility Study

BackgroundChildren and adolescents living under the supervision of child protective services have complex mental health care needs. The scarcity and uneven distribution of specialized mental health teams in Chile may limit the provision and quality of care for this vulnerable population. Telepsychiatry can address such health inequities.ObjectiveThe objective of this study was to evaluate the feasibility of a telepsychiatry consultation program for primary health care (PHC) treatment of children and adolescents living under the supervision of child protective services.MethodsWe developed a telepsychiatry consultation program for two rural PHC clinics located in central Chile (Valparaíso Region) and evaluated its implementation using a mixed methods study design. The program consisted of videoconferencing mental health consultation sessions scheduled twice per month (each 90 minutes long), over a 6-month period, delivered by child and adolescent psychiatrists based in Santiago, Chile. We described the number of mental health consultation sessions, participant characteristics, perceived usefulness and acceptability, and experiences with the telepsychiatry consultation program.ResultsDuring the 6-month study period, 15 videoconferencing mental health consultation sessions were held. The telepsychiatry consultation program assisted PHC clinicians in assigning the most adequate diagnoses and making treatment decisions on pharmacotherapy and/or psychotherapy of 11 minors with complex care needs. The intervention was perceived to be useful by PHC clinicians for improving the resolution capacity in the treatments of this patient population. Limitations such as connectivity issues were resolved in most sessions.ConclusionsThe telepsychiatry consultation program was feasible and potentially useful to support PHC clinicians in the management of institutionalized children and adolescents with complex psychosocial care needs living in a poorly resourced setting. A larger scale trial should assess clinical outcomes in the patient population. Regulations and resources for this service model are needed to facilitate sustainability and large-scale implementation.     

Barriers to Prenatal Care for Mexican and Mexican American Women

Despite the presumed health benefits, Latinas are less likely than women from other ethnic groups to receive adequate prenatal care during their pregnancy. However, it is unclear whether this trend is the result of political economic conditions that limit access of many Latinos in the United States to adequate health services in general, or of sociocultural conditions that restrict the use of such services even when they are made available. Furthermore, it is unclear whether these barriers pose a risk for adverse birth outcomes in this population. To address these issues, we conducted a two-phase study of the political economic and sociocultural barriers to use of prenatal care services among Mexican and Mexican American women living in San Diego, California, and their association with adverse birth outcomes in this population. A quantitative assessment of information abstracted from the medical records of 173 Latinas who had given birth at a university medical center found that absence of Medi-Cal benefits or other forms of health insurance was the only significant predictor of inadequate prenatal care during pregnancy. However, neither lack of insurance nor adequate prenatal care was associated with any adverse birth outcomes. A qualitative analysis of information obtained from interviews of 30 Latinas receiving prenatal care services at a medical clinic for the homeless and medically underserved residents of San Diego identified three major themes underlying the lack of adequate prenatal care: lack of trust in formal versus informal institutions, wanted versus unwanted pregnancies, and the importance of the social network.     

郴州农村妇女卫生保健意识及健康教育需求调查

目的:了解湖南省郴州市农村妇女卫生保健意识及其健康教育需求,为进一步提高健康教育质量提供依据。方法:结合预防医学本科生社会实践,组织大学生对郴州市保和乡326名农村妇女进行问卷调查。结果:大部分调查对象的卫生保健意识较差,近1年来,40.5%的妇女出现过生殖道感染症状;卫生保健意识主要与年龄、文化程度有关(P0.05);调查对象对健康教育的需求主要是儿童保健、常见妇科疾病预防和孕产期保健等方面的知识。结论:应针对不同年龄、不同文化层次的农村妇女进行相应的健康教育,健康教育的方式应多种多样。大学生组织的社会实践活动在农村妇女的健康促进工作中有着重要的作用。     

Oral health and access to dental care – a comparison of elderly migrants and non-migrants in Germany

Objectives: To compare oral health, access barriers to dental care, oral health behavior and oral hygiene behavior of elderly German residents with and without immigration background.

Design: In this cross-sectional explorative study, a convenience sample (N?=?112, age?≥?60 years, 54% immigrants) was recruited in four dental practices in Hamburg, Germany. Oral health was assessed with Decayed/Missing/Filled Teeth (DMFT), Papillary Bleeding Index (PBI), and Approximal Plaque Index (API). Dental health was operationalized as number of decayed teeth, and poor oral hygiene based on a PBI?≥?40%. Access barriers and oral health behavior were assessed with a standardized questionnaire.

Results: While caries experience was similar in migrants and non-migrants (DMFT mean: 24.8 vs. 23.4, n.s.), significantly more teeth were decayed (5.3 vs. 2.1, p?p?=?0.002) and PBI (46.3% vs. 30.5%, p?=?0.016) were significantly higher in migrants. After adjusting for age, sex, income, education, and number of teeth, migrants still had on average 3 decayed teeth more than non-migrants. However, impact of migration background on poor oral health changed from OR?=?3.61 (p?=?0.007) to OR?=?1.05 (n.s.) after adjusting for confounders, mainly due to lower income in migrants. Fewer migrants had visited a dentist within the past 12 months, and migrants were less likely to have a regular dentist that they visit and more often indicated language or cost barriers than non-migrants.

Conclusion: Elderly German migrants have higher treatment needs than non-migrants. Likely causes are poorer oral hygiene and lower utilization of dental care services. Specific prevention programs targeting migrants are warranted to improve oral health in this disadvantaged group.     

Insurance + access not equal to health care: typology of barriers to health care access for low-income families

PURPOSE Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers.