The role of medical home in emergency department use for children with developmental disabilities in the United States.

OBJECTIVE: Children with developmental disabilities (DDs) have higher rates of emergency department use (EDU) than their typically developing peers do. This study sought to elucidate the relationship between EDU frequency and access to a comprehensive medical home for children with DD. METHODS: This study conducted multivariate logistic regression analysis on data from the 2005-2006 National Survey of Children with Special Health Care Needs to explore the association between EDU frequency among children with DD and medical home. RESULTS: Compared with children with DD reporting zero EDU, children with 3 or more EDU were less likely to report access to usual health care source (adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.45-0.88). Moreover, children with DD who had 3 or more EDU were less likely to have clinicians who listen to parental concerns (AOR, 0.58; 95% CI, 0.45-0.76), demonstrate sensitivity toward family values and customs (AOR = 0.60, 95% CI = 0.46, 0.78), and build meaningful family partnerships (AOR, 0.69; 95% CI, 0.53-0.89). CONCLUSIONS: The study suggests that children with DD reporting 3 or more EDU per year would likely reduce their EDU by having access to usual source of primary care services and to clinicians with skills in building meaningful partnership with the parents. The inclusion of these medical home attributes in the adoption of patient-centered medical homes with the implementation of the Affordable Care Act presents a mechanism to improve care at lower cost as well as facilitate chronic disease management and coordination between emergency medicine and primary care physicians that may lead to reductions in EDU and unnecessary hospitalization.

The creation of the federal MCH Extramural Research Program, 1950-1969: lessons for today.

On April 9, 1912, the law establishing the Children's Bureau was signed by President William Howard Taft. The original mission of the Children's Bureau was to "investigate and report … upon all matters pertaining to the welfare of children and child life among all classes of our people." This paper focuses on the transitional years from roughly 1950 to 1969, when the Children's Bureau's investigative mandate was transformed from a set of intramural activities that viewed maternal and child health research as part of a larger effort cutting across investigative, programmatic, and policy goals, and across different domains of the child's life, to an extramural research program focused specifically on maternal and child health. Discussion focuses on the mission of the Maternal and Child Health (MCH) Research Program, housed now within the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), of the U.S. Department of Health and Human Services.

High parenting aggravation among US immigrant families.

OBJECTIVES: We examined the association between the joint effects of children's immigrant family type and race/ethnicity on parenting aggravation. METHODS: We analyzed data on a nationally representative sample of 101 032 children aged birth through 17 years from the 2003 National Survey of Children's Health. RESULTS: Analysis of the Aggravation in Parenting Scale showed that 26% of foreign-born parents with foreign-born children were highly aggravated, followed by 22% of foreign-born parents with US-born children and 11% of US-born parents. Multivariable analyses indicated that all minority parents experienced high parenting aggravation compared with non-Hispanic White US-born parents; the odds of reporting parenting aggravation were 5 times higher for Hispanic foreign-born parents. All foreign-born parents, regardless of race/ethnicity, reported significantly elevated parenting aggravation. Parents of adolescents, children with special health care needs, and nontraditional and lower-income households were also more likely to report high parenting aggravation. CONCLUSIONS: Our findings clearly document significantly elevated levels of parenting aggravation among immigrant and minority families. Public health programs and clinicians should target referrals and interventions for these families to avoid potential health problems for both children and their families.

Health status and health services access and utilization among Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese children in California.

OBJECTIVES: We examined health status and health services access and utilization of Chinese, Filipino, Japanese, Korean, South Asian, Vietnamese, and non-Hispanic White children in California. METHODS: We analyzed aggregated data from the 2003 and 2005 California Health Interview Survey (648 Chinese, 523 Filipino, 235 Japanese, 308 Korean, 314 South Asian, 264 Vietnamese, and 8468 non-Hispanic White children aged younger than 12 years), examining the relationship between Asian ethnicities and outcomes. RESULTS: Compared with non-Hispanic White children, Korean children were 4 times more likely to lack health insurance; Filipino children were twice as likely to not have had recent contact with a doctor; Chinese, Korean, and Vietnamese children were less likely to have visited an emergency room in the past year; and Chinese, Korean, and Vietnamese children were more likely to be in fair or poor health. Age, gender, poverty, citizenship-nativity status, health insurance, and parental marital and child health statuses were related to most outcomes. CONCLUSIONS: Asian ethnicities have heterogeneous health care access and utilization patterns, suggesting the need for targeted outreach to different Asian ethnic groups.

Disparities in obesity and overweight prevalence among US immigrant children and adolescents by generational status.

We examined the prevalence and socio-behavioral correlates of obesity and overweight among 46,707 immigrant and US-born children and adolescents aged 10-17 years. The 2003 National Survey of Children's Health was used to estimate obesity and overweight prevalence among children in 12 immigrant groups, stratified by race/ethnicity and generational status. Logistic regression was used to examine immigrant differentials in the prevalence and odds of obesity and overweight. Obesity and overweight prevalence varied from a low of 6 and 18% for second-generation Asian immigrants to a high of 24 and 42% for native-born black children (US-born black children with US-born parents), respectively. After adjusting for age, gender, ethnicity, socioeconomic status, perceived neighborhood safety, television viewing, computer use, and physical activity, first-generation immigrant children, overall, had 26% lower odds of obesity than native-born children. Obesity and overweight prevalence was lower for immigrant black and white children than their native-born counterparts, while obesity and overweight prevalence among Hispanic children did not vary significantly by generational status. Compared with native-born white children, the adjusted odds of obesity were 64% higher for native-born blacks, 55% higher for second-generation Hispanic immigrants, and 63% lower for first-generation Asian immigrants. Adjusted immigrant differentials in overweight risks were also marked. Socioeconomic, demographic, and behavioral factors accounted for 61 and 35% of ethnic-immigrant disparities in obesity and overweight prevalence, respectively. Immigrant patterns in childhood obesity and overweight vary substantially by ethnicity and generational status. To reduce disparities, obesity prevention programs must target at-risk children of both immigrant and US-born parents.

Beyond medical insurance: delayed or forgone care among children in Chinese immigrant families.

While Asian Americans are less likely than most Americans to use health services, little is known about their barriers to pediatric care. This study seeks to describe the prevalence of delayed/forgone pediatric care and its association with parental acculturation status in recent-immigrant Chinese families. Survey data were obtained from 76 families across two community services sites. Half of the surveyed families reported delayed/forgone pediatric care in the previous 12 months. Low-income families in suburban areas reported greater financial burdens, linguistic barriers, and a higher prevalence of delayed/forgone care than low-income families living in downtown area. Middle class immigrant families reported cultural barriers as a reason for delayed/forgone care. Traditional beliefs and not medical insurance were significant predictors of delayed/forgone care. Culturally and linguistically appropriate studies on risk reduction interventions will be needed to address the linguistic and cultural barriers to health care access.

Infant Mortality in the United States, 1915-2017: Large Social Inequalities have Persisted for Over a Century.

OBJECTIVES: We examined trends in racial/ethnic, socioeconomic, and geographic disparities in age- and cause-specific infant mortality in the United States during 1915-2017. METHODS: Log-linear regression and inequality indices were used to analyze temporal infant mortality data from the National Vital Statistics System and the National Linked Birth/Infant Death files according to maternal and infant characteristics. RESULTS: During 1915-2017, the infant mortality rate (IMR) declined dramatically overall and for black and white infants; however, black/white disparities in mortality generally increased through 2000. Racial disparities were greater in post-neonatal mortality than neonatal mortality. Detailed racial/ethnic comparisons show an approximately five-fold difference in IMR, ranging from a low of 2.3 infant deaths per 1,000 live births for Chinese infants to a high of 8.5 for American Indian/Alaska Natives and 11.2 for black infants. Infant mortality from major causes of death showed a downward trend during the past 5 decades although there was a recent upturn in mortality from prematurity/low birthweight and unintentional injury. In 2016, black infants had 2.5-2.8 times higher risk of mortality from perinatal conditions, sudden infant death syndrome, influenza/pneumonia, and unintentional injuries, and 1.3 times higher risk of mortality from birth defects compared to white infants. Educational disparities in infant mortality widened between 1986 and 2016; mothers with less than a high school education in 2016 experienced 2.4, 1.9, and 3.7 times higher risk of infant, neonatal, and post-neonatal mortality than those with a college degree. Geographic disparities were marked and widened across regions, with states in the Southeast region having higher IMRs. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS: Social inequalities in infant mortality have persisted and remained marked, with the disadvantaged ethnic and socioeconomic groups and geographic areas experiencing substantially increased risks of mortality despite the declining trend in mortality over time. Widening social inequalities in infant mortality are a major factor contributing to the worsening international standing of the United States.

State-level health care access and use among children in US immigrant families.

OBJECTIVES: We examined the association between children's state of residence and their access to health care among specific types of immigrant families: foreign-born children, US-born children with 1 foreign-born parent, US-born children with both foreign-born parents, and nonimmigrant families. METHODS: We analyzed data from 12 400 children from the 2003 National Survey of Children's Health in the 6 states with the highest proportion of immigrants (California, Florida, Illinois, New York, New Jersey, and Texas). RESULTS: Multivariable analyses indicated that among foreign-born children, those living in California, Illinois, and Texas were more likely to lack access to health care compared with those living in New York. Among foreign-born children with 1 or 2 US-born parents, Texas children were most likely to lack health insurance. Within nonimmigrant families, children from California, Florida, and Texas had significantly more access and use problems. CONCLUSIONS: Our findings document differential health care access and use among states for specific immigrant family types.

Differential effects of stress and African ancestry on preterm birth and related traits among US born and immigrant Black mothers.

Preterm birth (PTB, <37 weeks of gestation) is influenced by a wide range of environmental, genetic and psychosocial factors, and their interactions. However, the individual and joint effects of genetic factors and psychosocial stress on PTB have remained largely unexplored among U.S. born versus immigrant mothers.We studied 1121 African American women from the Boston Birth Cohort enrolled from 1998 to 2008. Regression-based analyses were performed to examine the individual and joint effects of genetic ancestry and stress (including lifetime stress [LS] and stress during pregnancy [PS]) on PTB and related traits among U.S. born and immigrant mothers.Significant associations between LS and PTB and related traits were found in the total study population and in immigrant mothers, including gestational age, birthweight, PTB, and spontaneous PTB; but no association was found in U.S. born mothers. Furthermore, significant joint associations of LS (or PS) and African ancestral proportion (AAP) on PTB were found in immigrant mothers, but not in U.S. born mothers.Although, overall, immigrant women had lower rates of PTB compared to U.S. born women, our study is one of the first to identify a subset of immigrant women could be at significantly increased risk of PTB and related outcomes if they have high AAP and are under high LS or PS. In light of the growing number of immigrant mothers in the U.S., our findings may have important clinical and public health implications.

Parental English proficiency and children's health services access.

OBJECTIVES: We examined the relation between parents' level of English proficiency and their children's access to health care. METHODS: Using the 2001 California Health Interview Survey, we conducted bivariate and multivariate analyses of several measures of children's access to health care (current health insurance status, usual source of care, emergency room visits, delayed or forgone care, traveling to another country for health care, and perceived discrimination in health care) and their association with parents' English proficiency. RESULTS: Compared with English-speaking households, children in non-English-speaking households were more likely to lack health insurance, to not have doctor contact, and to go to other countries for health care and were less likely to use emergency rooms. Their parents were less likely to report their children's experiencing delayed or forgone care or discrimination in health care. CONCLUSION: English proficiency is a strong predictor of access to health insurance for children, and children in non-English-speaking families are especially likely to rely on other countries for their health care. English proficiency may mitigate the effects of race/ethnicity commonly observed in health care access and utilization studies.

Association of Provider Advice and Pregnancy Weight Gain in a Predominantly Hispanic Population.

OBJECTIVES: This study sought to determine whether women's report of gestational weight gain (GWG) advice from a health care provider is consistent with the Institute of Medicine (IOM) guidelines and the association between provider advice and women's weight gain during pregnancy. METHODS: Data came from the 2007 Los Angeles Mommy and Baby study (n = 3,402). The 1990 IOM GWG guidelines were used to define whether the provider's advice on weight gain and women's weight gain were below, within, or above the guidelines. RESULTS: Approximately 4 months after delivery, 18.8% of the women reported having not discussed weight gain with any health care providers during pregnancy. Among those who reported such discussions, 42% reported receiving weight gain advice from a health care provider within IOM guidelines, 16.5% below guidelines, and 10% above. An additional 13.5% reported the discussion but did not report the recommended weight gain amount. Compared with women who reported provider advice on weight gain within guidelines, women who reported advice below guidelines were 1.7 times (95% confidence interval [CI], 1.3-2.2) more likely to gain less than the IOM recommended amount. Women who reported provider advice above IOM guidelines were 2.0 times (95% CI, 1.4-2.9) more likely to exceed guidelines. CONCLUSIONS: There is a need for more women to receive advice consistent with the IOM GWG guidelines from their prenatal care providers. Intervention strategies are needed to educate providers about IOM guidelines and how to counsel on GWG.

Delayed or forgone care among children with special health care needs: an analysis of the 2001 National Survey of Children with Special Health Care Needs.

OBJECTIVE: To examine the associations of sociodemographic characteristics with both the prevalence and the causes of delayed or forgone care in a nationally representative sample of children with special health care needs. METHODS: Data were abstracted from the 2001 National Survey of Children with Special Health Care Needs. The families of children with special health care needs (CSHCN) who reported delayed or forgone care were asked about the reasons. The 12 reasons in the questionnaire were grouped into 5 categories. Bivariate and multivariate logistic regression analyses were conducted in SUDAAN to examine the relationship between sociodemographic characteristics of CSHCN and the incidence of delayed or forgone care by its reasons. RESULTS: Nearly 10% of CSHCN had experienced delayed or forgone health care in the past 12 months in 2001. Logistic regression showed that delayed or forgone care was more likely to be reported by the families of CSHCN who were adolescents, who had more severe limitations, lived in the South or West, lacked medical insurance, and who lived in families under or near the federal poverty line. Hispanics were more likely to report "lack of medical specialty" and "had language, communication, or cultural problems with provider." Both Hispanics and non-Hispanic others were twice as likely to report "provider not accessible" as reasons for the delayed or forgone care compared with non-Hispanic whites or blacks. conclusion: CSHCN with certain socioeconomic status and sociodemographic characteristics, as well as those with severe limitations in activity, were more likely to be affected by circumstances that result in delayed or forgone care.

Disparities in Healthcare Access and Utilization among Children with Autism Spectrum Disorder from Immigrant Non-English Primary Language Households in the United States.

BACKGROUND: The prevalence of autism spectrum disorder (ASD) in United State (US) has surged from 1 in 150 children in 2007 to 1 in 88 children in 2012 with substantial increase in immigrant minority groups including Hispanic and Somali children. Our study objective is to examine the associations between household language among children with ASD and national health quality indicators attainment. METHODS: We conducted bivariate and multivariate logistic regression analyses using cross-sectional data from the publicly-available 2009-2010 National Survey of Children with Special Health Care Needs (NS-CSHCN) to investigate the association between household language use and quality indicators of medical home, adequate insurance, and early and continuous screening. RESULTS: Approximately, 28% of parents of children with ASD from non-English primary language (NEPL) households reported their child having severe ASD as compared with 13% of parents from English primary language (EPL) households. Older children were more likely to have care that met the early and continuous screening quality indicator, while lower income children and uninsured children were less likely to have met this indicator. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS: Despite the lack of differences in the attainment of quality indicators by household language, the higher severity found in children in NEPL households suggests that they are exceptionally vulnerable. Enhanced early screening and identification for these children and supporting their parents in navigating the complex US health care delivery system would increase their participation in early intervention services. Immigration of children with special health care needs from around the world to the US has been increasing from countries with diverse healthcare systems. Our findings will help to inform policies and interventions to reduce health disparities for children with ASD from immigrant populations. As the prevalence of ASD has increased worldwide, understanding of the condition and care-seeking behavior in migrant populations is especially valuable.

Out-of-school time activity participation among US--immigrant youth.

BACKGROUND: Structured out-of-school time (OST) activities are associated with positive academic and psychosocial outcomes. METHODS: Data came from the 2007 National Survey of Children's Health, restricted to 36,132 youth aged 12-17 years. Logistic regression models were used to examine the joint effects of race/ethnicity and immigrant family type on the participation in OST activities. RESULTS: Compared with US-born (USB) non-Hispanic White youth with USB parents, USB Hispanic youth with USB parents were less likely to participate in sports, whereas non-Hispanic Black youth with immigrant parents were more likely to participate in sports. White youth with at least 1 immigrant parent had higher odds of participating in after-school clubs. All Hispanic youth were less likely to participate in after-school clubs. USB Hispanic youth, USB Black youth, and White youth and "other" youth with at least 1 immigrant parent had higher odds of engaging in community services. Youth from immigrant families had lower odds of doing paid work. CONCLUSIONS: Hispanic youth were less likely to participate in OST activities. Non-Hispanic youth with immigrant parents did not engage in fewer OST activities compared with USB White youth with USB parents. Intervention and recruitment strategies for OST activities may need to be customized for immigrant groups.

Acculturation and the health and well-being of U.S. immigrant adolescents.

PURPOSE: To examine the association of acculturation, as measured by language spoken at home, with the health, psychosocial, school, and parental risk factors of adolescents of various racial/ethnic groups. METHODS: Using the U.S. component of the 1997-98 World Health Organization Study of Health Behavior in School Children, bivariate and multiple logistic regression analyses were conducted of records for adolescents in four racial/ethnic groups to explore the relationship between the language spoken at home and outcome variables regarding health status and risks, psychosocial and school risk factors, and parental factors. Data were analyzed using Software for the Statistical Analysis of Correlated Data (SUDAAN). RESULTS: Adolescents of all racial and ethnic groups who primarily speak a language other than English at home are at elevated risk for psychosocial risk factors such as alienation from classmates and being bullied, and parental risk factors such as feeling that their parents are not able or willing to help them. Those who speak a combination of languages are also at risk for being bullied and for high parental expectations. Language spoken at home is generally not associated with health and safety measures for adolescents across racial/ethnic groups. CONCLUSIONS: Adolescents whose primary language at home is not English experience higher psychosocial, school, and parental risks than non-Hispanic white English-speakers. New immigrant youths of all races and ethnic groups would potentially benefit from preventive and risk-reduction services.

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

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

Association of language spoken at home with health and school issues among Asian American adolescents.

The study examined the association of language spoken at home with the school and health risks and behaviors of Asian American adolescents. Using the United States component of the 1997-1998 World Health Organization Study of Health Behavior in School Children, bivariate and multiple logistic regression analyses were conducted of records for Asian children to explore the relationship between language spoken at home and outcome variables regarding health behaviors, psychosocial and school risk factors, and parental factors. Compared to those who usually speak English at home, adolescents who usually speak another language, or who speak two languages equally, face a greater risk for health risk factors, psychosocial and school risk factors, and parental risk factors. Not speaking English at home was associated with higher health risks, including not wearing seat belts and bicycle helmets; higher psychosocial and school risk factors, including feeling that they do not belong at school, difficulty making new friends, and lacking confidence; and higher parental risks, including reporting that parents were not ready to help them or willing to talk to teachers. Adolescents less acculturated to the United States experience a variety of physical and psychosocial risks. School-based interventions such as early identification and outreach, needs assessment, and counseling and support services should be provided to immigrant students and their families.