Community Health Workers in Schools: A Systematic Review

BackgroundCommunity health workers (CHWs) are trusted community members who provide health education and care. However, no consensus exists regarding whether community health worker-based interventions are effective within the school setting.ObjectiveTo determine outcomes and best practices of school-based community health worker interventions.Data SourcesPubMed, CINAHL, and SCOPUS databases.Study Eligibility CriteriaThis systematic literature review examined articles that described an intervention led by community health workers, targeted children and/or parents, and took place primarily within a Kindergarten-12^th grade school setting. Articles were excluded if they described an intervention outside the United States.ParticipantsCommunity health workers, children, and/or their parentsInterventionsSchool-based community health worker programsResultsOf 1875 articles identified, 13 met inclusion criteria and were included in the final analysis. Of these, 5 described a statistically significant primary outcome. Seven articles provided details regarding community health worker recruitment, training, and roles that would enable reproduction of the intervention.LimitationsThis review focused on interventions in the United States. Bias of individual studies had a wide range of scores (9–21). Heterogeneity of studies also precluded a meta-analysis of primary outcomes.Conclusions and Implications of Key FindingsThe utilization of Community health workers in school-based interventions for children and/or parents is promising. This review identified a lack of detail and uniformity in program presentation, specifically with Community health worker recruitment, training, and roles. A standardized reporting mechanism for Community health worker interventions in schools would better allow for reproducibility and scalability of existing studies.     

An economic analysis of the cost of survival of micro preemies: A systematic review

ObjectiveThis study aimed to systematically review the current literature on the economic costs of micro preemie as well as evidence on the cost-effectiveness of interventions to improve outcomes for micro preemie babies with a birth weight of ≤500 g.MethodWe searched MEDLINE, CINAHL, Scopus, ECONLIT, Business Source Premier and Cochrane Library for studies reporting costs of micro preemie from January 2000. Costs were inflated to 2019 United States dollars (US$). All full-text articles were assessed for eligibility and a quality assessment of included articles was conducted using the Drummond and the Larg and Moss checklists.ResultsThe search identified three studies that met the inclusion criteria; two cost-of-illness studies and one cost-effectiveness study. Across studies, the mean healthcare spending per micro preemie survivor (in 2019 US$) ranged from US$61,310 (birth admission) to US$263,958 (inpatient and outpatient for the first six months of life). One modelling study reported exclusive human milk diet for micro preemies at birth was more cost-effective compared to the standard approach with cow milk diet from the third-party payer and societal perspectives.ConclusionDespite significant advances in perinatal care and expanded access to life-saving equipment to improve survival outcomes of micro preemie, there remains a paucity of research on economic costs associated with these babies. No study has utilised quality-adjusted life-years as an outcome measure. Given the chronic conditions and long-term neurologic disability associated with micro preemie survivors, an estimate of the lifetime cost to the individual, healthcare providers and society would provide a benchmark of the potential cost-savings that could accrue from cost-effective interventions to improve the survival rate of micro preemies.     

Interventions to improve screening and follow-up in primary care: a systematic review of the evidence

BackgroundThe American Academy of Pediatrics and other organizations recommend several screening tests as part of preventive care. The proportion of children who are appropriately screened and who receive follow-up care is low.ObjectiveTo conduct a systematic review of the evidence for practice-based interventions to increase the proportion of patients receiving recommended screening and follow-up services in pediatric primary care.Data SourceMedline database of journal citations.Study Eligibility Criteria, Participants, and InterventionsWe developed a strategy to search MEDLINE to identify relevant articles. We selected search terms to capture categories of conditions (eg, developmental disabilities, obesity), screening tests, specific interventions (eg, quality improvement initiatives, electronic records enhancements), and primary care. We searched references of selected articles and reviewed articles suggested by experts. We included all studies with a distinct, primary care-based intervention and post-intervention screening data, and studies that focused on children and young adults (≤21 years of age). We excluded studies of newborn screening.Study Appraisal and Synthesis MethodsAbstracts were screened by 2 reviewers and articles with relevant abstracts received full text review and were evaluated for inclusion criteria. A structured tool was used to abstract data from selected articles. Because of heterogeneous interventions and outcomes, we did not attempt a meta-analysis.ResultsFrom 2547 returned titles and abstracts, 23 articles were reviewed. Nine were pre-post comparisons, 5 were randomized trials, 3 were postintervention comparisons with a control group, 3 were postintervention cross-sectional analyses only, and 3 reported time series data. Of 14 articles with preintervention or control group data and significance testing, 12 reported increases in the proportion of patients appropriately screened. Interventions were heterogeneous and often multifaceted, and several types of interventions, such as provider/staff training, electronic medical record templates/prompts, and learning collaboratives, appeared effective in improving screening quality. Few articles described interventions to track screening results or referral completion for those with abnormal tests. Data were often limited by single-site, nonrandomized design.ConclusionsSeveral feasible, practice- and provider-level interventions appear to increase the quality of screening in pediatric primary care. Evidence for interventions to improve follow-up of screening tests is scant. Future research should focus on which specific interventions are most effective, whether effects are sustained over time, and what interventions improve follow-up of abnormal screening tests.     

Evidence for family-centered care for children with special health care needs: a systematic review

ObjectiveFamily-centered care (FCC) has received widespread endorsement for use in care in the United States. In this study, we conducted a systematic review of evidence for FCC focusing specifically on family-provider partnership as the activity that constitutes FCC.MethodsWe found and reviewed articles from the medical, nursing, psychology, and sociology literature spanning 1986 to 2010. We also reviewed articles obtained through related references and through recommendations from key informants. Four sets of terms were used to search, including FCC, child/adolescent, children with special health care needs (CSHCN, defined broadly or by condition), and a relevant outcome.ResultsTwenty-four studies met the review criteria. Eight were cross-sectional studies from the National Survey of Children With Special Health Care Needs, and 7 were reports of randomized, controlled trials. Of the 24 articles reviewed, 13 examined populations of CSHCN or similar populations, 6 examined children with asthma, and the remaining studied children with other specific conditions. We found positive associations of FCC with improvements in efficient use of services, health status, satisfaction, access to care, communication, systems of care, family functioning, and family impact/cost. There was little available evidence, however, for some outcomes, including cost and transition.ConclusionsThe available evidence suggests that FCC is associated with improved outcomes for CSHCN. With positive findings for most of the studies reviewed here and the compelling arguments for FCC, we recommend the use of this approach by individuals and organizations.     

Parental Limited English Proficiency and Health Outcomes for Children With Special Health Care Needs: A Systematic Review

BackgroundOne in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.ObjectiveTo conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.Data SourcesPubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.Eligibility CriteriaUS studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.MethodsThree trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.ResultsFrom 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.Conclusions and ImplicationsParental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.     

International electives at the university of Minnesota global pediatric residency program: opportunities for education in all Accreditation Council for Graduate Medical Education competencies

PurposeGlobally competent pediatricians are in demand because of the increasing numbers of children from immigrant families living in the United States and the shortages of health care workers in low-income countries where the majority of the worlds' children live. This study sought to better understand the educational outcomes of international electives taken by pediatric residents training in global health.MethodsThirty-two pediatric residents who participated in an international elective as part of a global health curriculum completed reflective essays which were analyzed for themes from 2006 to 2010. During the first-order analysis, the emergent themes mapped to the Accreditation Council for Graduate Medical Education (ACGME) competencies. In response, a second-order analysis re-examined the essays with an additional researcher to support categorization consistent with the ACGME competencies.ResultsMore than 90% of essays described experiences related to medical knowledge, patient care and systems-based practice. More than 50% included reflections on practice-based learning and improvement, professionalism, and interpersonal and communication skills. Residents also described the impact on their personal and professional development.ConclusionInternational electives can provide educational opportunities for residents to develop competency in each of the 6 ACGME domains and to reevaluate their life purpose and career goals. In addition to opportunities to increase their medical knowledge, patient care and communication skills, residents find international electives rich learning environments for systems-based practice, practice-based learning/improvement, and professionalism, domains that can be challenging to teach. These findings support the importance of international electives in global health in meeting core requirements in residency training.     

Profiling health and health-related services for children with special health care needs with and without disabilities

ObjectiveThe aims of this study were to profile and compare the health and health services characteristics for children with special health care needs (CSHCN), with and without disabilities, and to determine factors associated with unmet need.MethodsSecondary data analysis of the 2005–2006 National Survey of Children with Special Health Care Needs was conducted. The sociodemographics, health, and health services of CSHCN with and without disabilities were compared. Multivariable logistic regression was employed to examine factors associated with unmet need for health services.ResultsChildren from minority racial and ethnic groups and children living in or near poverty were over-represented among CSHCN with disabilities, compared with other CSHCN. Statistically higher percentages of CSHCN with disabilities had behavioral problems (39.6% vs 25.2%), anxiety/depressed mood (46.1% vs 24.0%), and trouble making/keeping friends (38.1% vs 15.6%) compared with other CSHCN. Thirty-two percent of CSHCN with disabilities received care in a medical home compared with 51% of other CSHCN. CSHCN with disabilities had higher rates of need and unmet need than other CSHCN for specialty care, therapy services, mental health services, home health, assistive devices, medical supplies, and durable medical equipment. The adjusted odds of unmet need for CSHCN with disabilities were 71% higher than for other CSHCN.ConclusionCSHCN with disabilities had more severe health conditions and more health services need, but they less commonly received care within a medical home and had more unmet need. These health care inequities should be amenable to policy and health service delivery interventions to improve outcomes for CSHCN with disabilities.     

Spanish-Speaking Parents’ Experiences Accessing Academic Medical Center Care: Barriers,Facilitators and Technology Use

Background and ObjectiveChildren of Spanish-speaking caregivers face multiple barriers to care in academic medical centers. This study identified barriers and facilitators of health care and described use of health information technology in order to guide interventions and optimize services.MethodsIn-depth, audiotaped interviews were conducted with monolingual Spanish-speaking caregivers (N = 28) of children receiving care in academic medical center clinics using a structured interview guide. Interviews were transcribed in Spanish, and key themes were identified using thematic analysis. Illustrative quotes for each theme were translated into English.ResultsLanguage-specific barriers included arrival/registration occurring in English, lack of bilingual personnel, heavy reliance on interpreters, long wait times, and challenging phone communication. Non–language-specific barriers included medical center size and complexity, distance to services, lack of convenient and coordinated appointments, missing work/school, and financial barriers including insurance coverage or lack of citizenship. Caregivers identified interpreters, bilingual physicians and staff, and written materials in Spanish as facilitators of care. Most caregivers had internet access and expressed interest in health information technology, including patient portals, to communicate about their children's health.ConclusionsCaregivers of Spanish-speaking children encounter many language-specific barriers, which are compounded by non–language-specific barriers arising from complex health systems and social needs. Caregivers with limited resources described working hard to meet children's complex health care needs despite these barriers. Most caregivers had internet access and interest in patient portals. Academic medical centers may need multifaceted interventions that improve the availability of bilingual staff and interpreters and also address caregivers' social and informational needs.     

How can quality improvement enhance the lives of children with disabilities?

Much attention has aided measurement and improvement in the quality of health care during the past two decades, with new ways to define and measure quality, recognition that doing so can identify strategies to enhance care, and systematic efforts by both government and private insurers to apply these principles. In this article, James Perrin reviews these gains. Although children have benefited, these quality measurement efforts have focused mainly on adult health care. Now, two recent federal programs promise to expand quality measurement of child health care. Enacted in 2009, the Children's Health Insurance Program Reauthorization Act provides systematic support for efforts to develop and implement a set of child health quality measures. This federal support represents the first major public investment in improving child health care quality. The Affordable Care Act, which became law in 2010, extends those activities by focusing attention on improving care for people with chronic conditions, including new ways to organize care using teams of doctors, nurses, and others focused on improving chronic care outcomes. For children especially, this team care should also focus on prevention of chronic conditions and their consequences. Despite these significant efforts to expand quality measurement among children and youth, Perrin finds that most measures and improvement activities focus on children without chronic conditions, and few measures of chronic conditions go beyond examining what kinds of monitoring children with specific conditions receive. Only limited attention is paid to how well the children are functioning. A number of networks working with children with specific chronic health conditions (such as cancer, cystic fibrosis, and sickle cell disease) have developed effective measures of functioning for children with those conditions and active programs to improve such outcomes. These networks offer the best examples of how to improve care and outcomes for young people with disabilities. Broadening their impact to larger numbers of children with disabilities will require developing measures of functioning and quality of life and targeting interventions and efforts to improve those outcomes.     

Continuity of Care in Primary Care for Young Children With Chronic Conditions

Objectives1) To assess continuity of care (CoC) within primary-care practices for children with asthma and autism spectrum disorder (ASD) compared to children without chronic conditions, and 2) to determine patient and clinical-care factors associated with CoC.MethodsRetrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0–1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits.ResultsOf 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean = 0.58, SD 0.21) and ASD (M = 0.57, SD = 0.20) than Controls (M = 0.66, SD = 0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR = 0.90, 95% CI, 0.85–0.94). Lower overall and well-care CoC were associated with public insurance (aOR = 0.77, CI, 0.74–0.81; aOR = 0.64, CI, 0.59–0.69).ConclusionAfter accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary-care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC.     

Hábitos alimentarios de niños menores de 2 años según el origen étnico de los progenitores en un área urbana de Barcelona

IntroductionThe importance of the influence of diet in the first few years of life on child growth and development and its relationship with the prevention of chronic diseases in childhood and adulthood has recently been stressed. The aim of the present study was to determine the presence or absence of inappropriate feeding practices, defined as non-compliance with dietary recommendations, in children aged less than 2 years old through a survey.Subjects and methodsThe parents of 462 children were administered a 14-item questionnaire on compliance with dietary recommendations to define nutritional risk. Depending on the parents’ country of birth, children were classified as autochthonous, gypsy, or non-autochthonous.ResultsIn absolute results, high percentages of non-compliance with a substantial number of recommendations were found in all children and in each of the three groups, with the consequent danger of nutritional risk.ConclusionsIn children in our environment, there are numerous inadequate feeding practices that constitute nutritional risk factors and require preventive and educational interventions to improve the future health of these children when they reach adulthood. In children from ethnic groups, no particularly severe inadequate feeding practices related to origin were found. The gypsy ethnic group requires additional nutritional health education interventions. Health workers should improve the information provided on nutritional recommendations and feeding practices to avoid misunderstanding, as in the case of gluten.     

Strengthening PNP Curricula in Mental/Behavioral Health and Evidence-based Practice

IntroductionThe incidence of mental health/behavioral and developmental problems in children and teens is escalating. However, many primary care providers report inadequate skills to accurately screen, identify, and manage these problems using an evidence-based approach to care. Additionally, educational programs that prepare pediatric nurse practitioners (PNPs) have been slow to incorporate this content into their curriculums.MethodsThe purpose of this project was to implement and evaluate a strengthened curriculum in 20 PNP programs from across the United States that focused on: (a) health promotion strategies for optimal mental/behavioral health and developmental outcomes in children, and (b) screening and evidence-based interventions for these problems. An outcomes evaluation was conducted with faculty and graduating students from the participating programs along with faculty and students from 13 PNP programs who did not participate in the project.ResultsParticipating schools varied in the speed at which components of the strengthened curriculum were incorporated into their programs. Over the course of the project, faculty from participating programs increased their own knowledge in the targeted areas and reported that their students were better prepared to assess and manage these problems using an evidence-based approach. Although reports of screening for certain problems were higher in the graduating students from the participating schools than the non-participating schools, the overall use of screening tools by students in clinical practice was low.DiscussionThere is a need for educational programs to strengthen their curricula and clinical experiences to prepare students to screen for, accurately identify, prevent, and provide early evidence-based interventions for children and teens with mental health/behavioral and developmental problems. This project can serve as a national model for curriculum change.     

Using Large Aggregated De-Identified Electronic Health Record Data to Determine the Prevalence of Common Chronic Diseases in Pediatric Patients Who Visited Primary Care Clinics

ObjectiveWe used de-identified clinical data from multiple health care systems using different electronic health records (EHRs) to 1) quantify the prevalence of common pediatric chronic diseases, 2) investigate patent characteristics associated with common pediatric chronic diseases, and 3) compare the results of our methodology to determine chronic disease prevalence with traditional approaches.MethodsWe used a HIPAA-compliant and de-identified web application (Explorys; IBM Watson Health Explorys Inc.) to identify patients 17 years old or younger from multiple health care systems in the US who were seen in primary care clinics between 2016-2018 to determine the most common chronic conditions in this age group. The prevalence of chronic conditions was compared between different age groups, genders, races/ethnicities, and insurance; odds ratios and confidence intervals were calculated and reported.ResultsThe top 6 chronic conditions identified by prevalence were: obesity/overweight (36.7%), eczema (15.8%), asthma (12.7%), food allergies (4.7%), attention deficit-hyperactivity disorder (4.09%) and hypertension (4.07%). Chronic conditions were generally more prevalent among relatively older pediatric patients, males, and African-American and multiracial groups.ConclusionsApproximately 40% of children and adolescents have at least one chronic disease. Obesity/overweight, eczema, and asthma are the most common chronic diseases of childhood, in the US, among those seeking care in health care systems with EHRs. The work compiled herein demonstrates that aggregated, standardized, normalized and de-identified population-level EHR data can provide both sufficient insight and statistical power to calculate the prevalence of chronic diseases and the odds ratio of various risk factors.     

Impact of Environmental Tobacco Smoke on Children With Asthma,United States, 2003–2010

ObjectiveGiven widespread interventions to reduce environmental tobacco smoke (ETS) exposure and improve asthma control, we sought to assess the current impact of ETS exposure on children with asthma.MethodsWe analyzed 2003–2010 data for nonsmoking children aged 6 to 19 years with asthma from the National Health and Nutrition Examination Survey. Outcomes (sleep disturbance, missed school days, health care visits, activity limitation, and wheezing with exercise) were compared between ETS exposed children (serum cotinine levels 0.05 to 10 ng/mL) and unexposed children (<0.05 ng/mL) using ordinal regression adjusted for demographic characteristics. We also assessed whether associations were observable with low ETS exposure levels (0.05 to 1.0 ng/mL).ResultsOverall, 53.3% of children aged 6 to 19 years with asthma were ETS exposed. Age-stratified models showed associations between ETS exposure and most adverse outcomes among 6- to 11-year-olds, but not 12- to 19-year-olds. Even ETS exposure associated with low serum cotinine levels was associated with adverse outcomes for 6- to 11-year-olds. Race-stratified models for children aged 6 to 19 years showed an association between ETS exposure and missing school, health care visits, and activity limitation due to wheezing among non-Hispanic white children, and disturbed sleep among non-Hispanic white and Mexican children. Among non-Hispanic black children, there was no elevated risk between ETS exposure and the assessed outcomes: non-Hispanic black children had high rates of adverse outcomes regardless of ETS exposure.ConclusionsAmong children with asthma 6 to 11 years of age, ETS exposure was associated with most adverse outcomes. Even ETS exposure resulting in low serum cotinine levels was associated with risks for young children with asthma.     

Annual Days With a Health Care Encounter for Children and Youth Enrolled in Medicaid: A Multistate Analysis

ObjectiveTo assess the number of days that children experienced a health care encounter and associations between chronic condition types and health care encounters.MethodsRetrospective analysis of data from 5,082,231 children ages 0 to 18 years enrolled in Medicaid during 2017 in 12 US states contained in the IBM Watson Marketscan Medicaid Database. We counted and categorized enrollees’ encounter days, defined as unique days a child had a health care visit, by type of health service. We used International Classification of Disease-10 diagnosis code categories from Agency for Healthcare Research and Quality's Chronic Condition Indicator System to identify chronic mental and physical health conditions.ResultsMedian (interquartile range [IQR]) annual encounter days was 6 (2–13). Children in the 91st to 98th and ≥99th percentiles for encounter days experienced a median of 49 (IQR 38–70) and 229 (IQR 181, 309) days, respectively; these children accounted for 52.6% of days for the cohort. As encounter days increased from the 25th to >90th percentile, the percentage of children with co-existing mental and physical health conditions increased from <0.1% to 47.4% (P < .001). Outpatient visits accounted for a total of 68.3% and 62.2% of days for children the 91st to 98th and ≥99th percentiles.ConclusionTen percent of children enrolled in Medicaid averaged health care encounters at least 1 day per week; 1% experienced health care encounters on most weekdays. Further investigation is needed to understand how families perceive frequent health care encounters, including how to facilitate their children's care in the most feasible way.