Planning for health promotion in low-income preschool child care settings: focus groups of parents and child care providers.

OBJECTIVE: To identify potentially successful strategies, barriers, and facilitators for health promotion in preschool child care settings. METHODS: We conducted 6 focus groups including each of the following: parents of children attending child care centers and home-based family child care (2 in English, 1 in Spanish) and directors of child care centers and family child care providers (2 in English, 1 in Spanish). Systematic thematic analysis was conducted to generate themes to address study questions. RESULTS: A total of 24 parents and 45 child care providers, serving predominantly urban, low-income children in Boston, participated. Parents and child care providers agreed that in-person group discussions would be the most effective strategy for providing health education information to parents. Several barriers that could affect implementation emerged. First, some providers expressed frustration toward parents' attitudes about child safety and health. Second, there was diversity of opinion among providers on whether conducting health promotion activities was consistent with their training and role. In addition, literacy, language, and cultural barriers were identified as potential barriers to health promotion in child care. CONCLUSIONS: In order to be successful, health promotion strategies in child care settings will need to overcome tensions between providers and parents, allow professional growth of child care providers to serve in a health promotion role, and better integrate external health resources and personnel. Group sessions and peer learning opportunities that are culturally and linguistically sensitive are potentially successful strategies for implementation of health promotion interventions for many parents.     

Mental health worries, communication, and needs in the year of the U.S. terrorist attack: national KySS survey findings.

INTRODUCTION: To reduce the escalating rate of mental health/psychosocial morbidities in children and adolescents, NAPNAP initiated a new national campaign entitled Keep your children/yourself Safe and Secure (KySS). The objective of the first phase of this campaign was to conduct a national survey to assess the mental health knowledge, attitudes, worries, communication, and needs for intervention of children/teens, parents, and pediatric health care providers. This first report from the KySS survey describes the child/teen and parental findings. METHODS: A cross-section of 621 children/teens and 603 of their parents from 24 states completed the KySS survey during visits to their primary health care providers. RESULTS: The five greatest worries of both children/teens and their parents included knowing how to cope with stressful things in their lives, anxiety, depression, parent-child relationships, and problems with self-esteem. The majority of children/teens and their parents reported that they do not talk to their primary care providers about these issues. Participants expressed a multitude of needs and suggestions regarding how to better recognize, prevent, and deal with mental health problems. CONCLUSION: Opportunities must be created for children/teens and their parents to communicate their mental health worries and needs to each other and to their pediatric primary care providers to facilitate earlier diagnosis and treatment of mental health problems. Interventions are urgently needed to assist children and teens in coping with the multitude of stressors related to growing up in today's society.     

Parents' mood and the content of pediatric care for young children.

OBJECTIVE: To assess the relationship between parents' mood and the provision of anticipatory guidance by pediatric health care providers. DATA SOURCE: Data analyzed were from the National Survey of Early Childhood Health, a cross-sectional nationally representative survey concerning young children 4-35 months of age (n = 2068). KEY VARIABLES: Parents were asked whether the children's health care providers had discussed 10-12 age-appropriate health promotion topics and 5 psychosocial issues during the past 12 months. Parents also identified missed opportunities for guidance (ie, topics not discussed for which discussion would have been helpful) and reported whether providers should discuss psychosocial issues. Parents' mood was assessed using factor scores derived from the Mental Health Inventory. ANALYSES: Log-linear regression analyses determined if parents' mood was a significant predictor of the number of topics and issues discussed, the number of missed opportunities, and the reported number of issues that providers should discuss. RESULTS: Parents who were more often in a positive mood discussed more health promotion topics (B =.06, P <.001) and psychosocial issues (B =.10, P <.01) with their child's health care providers. Parents who were more often in a negative mood identified more missed opportunities (B =.08, P =.02) and more issues that providers should discuss (B =.04, P <.001). CONCLUSIONS: Increased attention to parents' mood and emotional well-being may help pediatricians identify parents who desire additional anticipatory guidance and ensure that opportunities for the provision of guidance are not inadvertently missed.     

Reproductive health/family planning and the health of infants, girls and women

The 1994 International Conference on Population and Development developed international consensus amongst health providers, policy makers, and group representing the whole of civil society regarding the concept of reproductive health and its definition. In line with this definition, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. Reproductive health care saves lives and prevents significant levels of morbidity through family planning programmes, antenatal, delivery and post-natal services, prevention and management programmes for reproductive tract infections (including sexually trasmitted diseases and HIV/ AIDS), prevention of abortion and management of its complications, cancers of the reproductive system, and harmful practices that impact on reproductive function. Reproductive health care needs are evident at all stages of the life cycle and account for a greater proportion of disability adjusted life years (DALYS) in girls and women than in boys and men. Reproductive health protects infant health by enabling birth spacing and birth limitation to be practiced through family planning. The prevention and early detection of reproductive tract infections, including sexually transmitted diseases and HIV, through the integration of preventive measures in family planning service delivery not only improves the quality of care provided but is also directly responsible for improvement in survival and health of infants. Addressing harmful practices such as son preference, sex selection, sexual violence and female genital mutilation complements the positive impact of planned and spaced children through family planning services on infant mortality and the reproductive health of young girls and women. They are also in addition to prenatal, delivery and postnatal services, positive determinants of low maternal mortality and morbidity and are integral to the promotion of reproductive health in women of child bearing age. Reproductive tract infections, including sexually transmitted diseases and HIV contribute to significant level of ill-health in women of reproductive age and continue to pose a threat through the menopause which in turn brings with it increasing risk of cancers of the reproductive system.     

Promoting Child Development and Behavioral Health: Family Child Care Providers' Perspectives

IntroductionGiven the significant proportion of children in nonparental child care and the importance of early life experiences on development, interventions to improve a child care provider's ability to enhance a young child's development and behavior are essential. Such interventions require understanding of and responsiveness to the provider's self-perceived roles, responsibilities, and willingness to engage in such interventions, yet prior research is limited. The purpose of the study was to characterize licensed family child care provider perspectives as a first step toward designing effective provider-based interventions to improve children's development and behavior.MethodWe conducted a qualitative study using in-depth interviews with licensed family child care providers serving economically disadvantaged children. Interviews were audiotaped, transcribed, and synthesized into common themes using the constant comparative method of qualitative data analysis.ResultsThe family child care providers described five domains related to their role in child development and behavior: (a) promotion, (b) assessment, (c) advising parents, (d) acknowledging barriers, and (e) their own skill development.DiscussionThe family child care providers we interviewed describe how the developmental and behavioral health of children is an important aspect of their role and identify innovative and feasible ways to enhance their skills. Understanding the self-perceived role, responsibility, and willingness of child care providers is an important foundation to designing effective interventions to achieve high-quality child care.     

What do pediatric primary care providers think are important research questions? A perspective from PROS providers.

OBJECTIVE: To describe what pediatric primary care providers involved in the Pediatric Research in Office Settings (PROS) research network think are important yet inadequately addressed questions in pediatric primary care research. METHODS: A total of 1785 pediatric primary care providers in the PROS network were asked what they thought were important yet inadequately addressed areas of primary care research. We used a single, open-ended question in a mail survey. Written answers to this question were analyzed by qualitative methods to determine the main themes of interest to pediatric primary care providers. RESULTS: Overall survey response rate was 48.7%; the open-ended question yielded 1109 individual answers. Six lines of inquiry were identified as being important to these providers: (1) effective counseling techniques to use in anticipatory guidance; (2) strategies to prevent and treat obesity; (3) the effectiveness of well-child care; (4) ongoing management of patients with attention-deficit/hyperactivity disorder; (5) the role of the primary care provider in caring for children with mental health needs; and (6) optimal organization of office practices. CONCLUSIONS: The translation of research into practice may be improved by a better understanding of the needs and interests of those who see pediatric patients in the primary care setting.     

Addressing social barriers and closing the gender knowledge gap: exposure to road shows is associated with more knowledge and more positive beliefs, attitudes and social norms regarding exclusive breastfeeding in rural Zimbabwe

Exclusive breastfeeding (EBF) is rarely practiced despite its significant child survival benefits. A key constraint to increasing EBF rates in Zimbabwe and most of the developing world is that key decision makers (fathers/partners and other family members) are often poorly informed about EBF and do not attend antenatal clinics where health information is routinely provided. Informed by formative research, a district-wide campaign was conducted in rural Zimbabwe to encourage EBF and expressing and heat treating (EHT) breast milk as a means to maintain EBF. The campaign combined traditional strategies of education, counselling and outreach through health service delivery with a novel road show 'edutainment' intervention to reach men and other community members. A post campaign evaluation measured the association of road show exposure with 20 knowledge items and summative scores of social norms, beliefs and attitudes obtained through exploratory factor analysis. In adjusted models, road show exposure was associated with correct EBF knowledge (β=1.0, 0.001), EHT knowledge (β=1.3, P<0.001) and greater perceived benefits of condom use during pregnancy and breastfeeding (β=0.5, P<0.001), and more positive EBF social norms (β=0.6, P<0.001), EBF beliefs and attitudes (β=1.0, P<0.001) and attitudes towards condom use during breastfeeding (β=0.6, P<0.001). Road show exposure was more strongly associated with EBF knowledge among men (P-value for gender×exposure group interaction=0.03), suggesting that it also closed the knowledge gap between men and women. Longitudinal studies will determine whether road shows were associated with changes in EBF practices.     

Introduction to pediatric hospital medicine

This article provides a brief summary of the past, present, and future of pediatric hospital medicine. In its short history, it already has made an impact on the way pediatrics is practiced and taught. There is no denying Dr. Menna's prescience when he wrote his opinion in 1990. As the field continues to emerge and mature, the current leadership is cognizant of the obstacles ahead and the need to maintain the goal of the well-being of all children. Maintaining that goal means redoubling efforts to maintain contact with primary care providers for continuity of care in and out of the hospital. Only by promoting patient- and family-centered care, inclusive of all providers, can children's health best be served.     

Transition Care: Future Directions in Education,Health Policy,and Outcomes Research

All youth must transition from pediatric to adult-centered medical care. This process is especially difficult for youth with special health care needs. Many youth do not receive the age-appropriate medical care they need and are at risk during this vulnerable time. Previous research has identified barriers that may prevent effective transition, and protocols have been developed to improve the process. Health outcomes related to successful transition have yet to be fully defined.Health care transition can also be influenced by education of providers, but there are gaps in medical education at the undergraduate, graduate, and postgraduate levels. Current changes in federal health policy allow improved health care coverage, provide some new financial incentives, and test new structures for transitional care, including the evolution of accountable care organizations (ACO). Future work must test how these systems changes will affect quality of care. Finally, transition protocols exist in various medical subspecialties; however, national survey results show no improvement in transition readiness, and there are no consistent measures of what constitutes transition success.In order to advance the field of transition, research must be done to integrate transition curricula at the undergraduate, graduate, and postgraduate levels; to provide advance financial incentives and pilot the ACO model in centers providing care to youth during transition; to define outcome measures of importance to transition; and to study the effectiveness of current transition tools on improving these outcomes.     

The 18-month well-child visit in primary care: Clinical strategies for early intervention

Family physicians, paediatricians, nurse practitioners and all primary health care providers are well-positioned in the health care system to provide identification and intervention for developmental delay in early childhood. This can be accomplished through the promotion of healthy child development by supporting children and their parents, paying special attention to issues of attachment and parent-child interactions. Early recognition and intervention is critical for addressing all developmental, social and behavioural problems in young children. A familiarity with local community resources and services is crucial; it will assist primary health care providers in supporting families by providing extra assistance and assessment for families at risk. The present article reports on the evidence-based interventions at the 18-month visit including screening tools, resources and a case example. The importance of interdisciplinary coordination to provide a comprehensive approach to screening, assessment and intervention for developmental delays in infants and young children is highlighted.     

Breastfeeding promotion in Kenya: changes in health worker knowledge, attitudes and practices, 1982-89.

In 1982, a study of health worker knowledge, attitudes and practices with respect to breastfeeding was undertaken in Kenya. A breastfeeding promotion campaign ensued, in which training of health workers was a major component. In 1989, the impact of this campaign was evaluated through a survey examining changes in health worker knowledge, attitudes and practices. The survey showed that considerable improvements in knowledge and substantial improvements in hospital practices have occurred, although none of these could be attributed to any single element of the breastfeeding promotion programme. Particularly undesirable practices which were common in 1982, such as separation of mother and baby, formula feeding and use of bottles have virtually disappeared from Kenyan hospitals. Recommendations regarding future programme directions are made.     

Information through television: does it promote child safety?

OBJECTIVES: First, to evaluate whether a local campaign to prevent childhood injuries increased parents' inclination to follow eight television programmes broadcast nationwide, and second, to assess whether parents reached by a local campaign benefitted more from the television programmes than those not reached by the campaign. METHODS: Before the television programmes were broadcast, all families with preschool children living in a typical Swedish municipality (the intervention area) received a letter from the head of the child health services encouraging them to watch the programmes. The local campaign also included face-to-face information and advice on childhood injuries at all day care centres and child health centres in the intervention area. After all the programmes had been broadcast, telephone interviews were conducted with one parent from 77% of all 1699 households with at least one preschool child in the intervention area, and with 87% of a random sample of 144 parents from other, similar municipalities. RESULTS AND CONCLUSIONS: The local campaign increased parents' inclination to follow the programmes. No significant association was found, however, between the number of programmes followed and measures undertaken in the homes as a direct consequence of the programmes. Nor was a significant association found between the number of programmes viewed and parents' attitudes towards risks. A local campaign may increase parents' awareness of information provided by the mass media on childhood injuries.     

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.     

Early childhood caries in Indigenous communities: A joint statement with the American Academy of Pediatrics

The oral health of Indigenous children of Canada (First Nations, Inuit and Métis) and the United States (American Indian and Alaska Native) is a major child health issue. This is exemplified by the high prevalence of early childhood caries (ECC) with resulting adverse health effects, as well as high rates and costs of restorative and surgical treatments under general anesthesia. ECC is an infectious disease that is influenced by multiple factors, including socioeconomic determinants, and requires a combination of approaches for improvement. The present statement includes recommendations for oral health preventive and clinical care for young infants and pregnant women by primary health care providers, community-based health promotion initiatives, oral health workforce and access issues, and advocacy for community water fluoridation and fluoride varnish program access. Further community-based research on the epidemiology, prevention, management and microbiology of ECC in Indigenous communities would be beneficial.     

The economic impact of breastfeeding

Although breastfeeding is well accepted as the optimal method of infant feeding, the US failed to reach the goals set for the year 2000. Support from employers, health insurers, health providers, and society are required to reach the goals set forth in Healthy People 2010-75% of mothers initiate breastfeeding, 50% of infants still receive breast milk at 6 months, and 25% of infants are still breastfed at 1 year of age. In today's era of cost accountability and economic competition, these groups likely will desire information regarding the financial effects of breastfeeding and breastfeeding promotion from their perspectives. Although much research still is needed in this area, evidence suggests that a significant return on investment is likely with breastfeeding promotion. Also, the finances of health care must be viewed within the concept of value. In health care, value can be thought of as the cost required to achieve a specified outcome. In lay terms, this can be thought of as "how much bang we get for our buck." Breastfeeding clearly improves the health of infants and mothers and seems to result in cost savings for parents, insurers, employers, and society, which means that the medical and economic value of breastfeeding is high. To reap the health and economic benefits associated with breastfeeding, society must support breastfeeding promotion, which most likely will necessitate a coordinated US breastfeeding program. The US government is in a unique position to accomplish this goal as it views the associated costs from the joint perspectives of employer, health insurer, medical provider, and society. Through support of such a program, the US government likely will benefit significantly by improving the health of children and its financial bottom line.     

The choking game in adolescence, between experimentation and risk

In the last year there was happened a series of adolescent deaths in the province of Salta that might be related to a dangerous game known as "the choking game". It has been practiced over many years in different countries around the world and consists of provoking brain hypoxia for some seconds by different techniques to obtain an instant of ecstasy and pleasure. We consider relevant that health providers know about this practice and so be able to recognize through signs and symptoms when an adolescent might be playing this game.     

Long-term follow-up of children treated for cancer: why is it necessary, by whom, where and how?

About 1 in 715 young adults is a survivor of childhood malignancy, but these individuals are at increased risk of considerable treatment-related morbidity or even mortality. A recent study suggests that at least 60% have one or more chronic health problems, whilst about 20% have three or more. The principle goal of long-term follow-up (LTFU) of survivors is to decrease the severity of late treatment complications by performing appropriate surveillance to detect incipient toxicity, and by facilitating timely diagnosis and management of emerging or established late adverse effects. The content of LTFU is dictated by the type and amount of treatment for the malignancy, and has been defined in recent clinical guidelines. Moreover, LTFU allows provision of survivor education, psychosocial support and health promotion advice. However, considerable variation exists in how LTFU is performed, with several alternative models involving a range of professionals in a variety of locations, depending on numerous clinical and organisational factors. There is increasing utilisation of multidisciplinary teams, and recognition of the importance of effective transition strategies whereby care is transferred to more age-appropriate providers, usually after a period of joint care in adolescence. It is of paramount importance to ascertain and meet the needs of survivors themselves.     

Human Trafficking of Children: Nurse Practitioner Knowledge,Beliefs, and Experience Supporting the Development of a Practice Guideline: Part One

IntroductionUp to 87% of trafficking victims encounter a health care provider while being trafficked but are not recognized as victims. Most health care providers receive little or no training, and awareness remains low. To describe the knowledge, beliefs, and attitudes of pediatric advanced practice registered nurses about human trafficking.MethodA survey of the National Association of Pediatric Nurse Practitioners membership (n = 8,647) before the intervention measured knowledge, beliefs, and experience regarding child trafficking. An awareness campaign was implemented with continuing education, national media presence, Train the Trainer programs, and creation of a nonprofit organization to direct strategic initiatives.ResultsOverall, 799 (9%) NAPNAP members completed the survey. Although 87% believed it possible that they might encounter a victim of trafficking in their practice, 35% were unsure if they had provided care for a victim. Only 24% reported confidence in their ability to identify a child at risk for trafficking.DiscussionThese survey findings indicate the need for clinical practice guidelines to identify potential and actual victims of human trafficking. Pediatric advanced practice registered nurses are ideally equipped and situated to intervene on behalf of vulnerable children with health disparities in a myriad of care settings, advocating for prevention and optimization of equitable health outcomes.