Medical-Legal Strategies to Improve Infant Health Care: A Randomized Trial.

BACKGROUND: Changes in health care delivery create opportunities to improve systems to better meet the needs of low-income families while achieving quality benchmarks. METHODS: Families of healthy newborns receiving primary care at a single large urban safety-net hospital participated. Intervention families were randomly assigned a family specialist who provided support until the 6-month routine health care visit. The Developmental Understanding and Legal Collaboration for Everyone (DULCE) intervention is based on the Strengthening Families approach and incorporated components of the Healthy Steps and Medical-Legal Partnership models. Medical record reviews determined use of preventive and emergency care. Surveys conducted at baseline, postintervention (6 months), and follow-up (12 months) were used to determine hardship and attainment of concrete supports. RESULTS: Three hundred thirty families participated in the study. At baseline, 73% of families reported economic hardships. Intervention parents had an average of 14 contacts with the family specialist, and 5 hours of total contact time. Intervention infants were more likely to have completed their 6-month immunization schedule by age 7 months (77% vs 63%, P < .005) and by 8 months (88% vs 77%, P < .01). Intervention infants were more likely to have 5 or more routine preventive care visits by age 1 year (78% vs 67%, P < .01) and were less likely to have visited the emergency department by age 6 months (37% vs 49.7%, P < .03). The DULCE intervention accelerated access to concrete resources (P = .029). CONCLUSIONS: Assignment to the Project DULCE intervention led to improvements in preventive health care delivery and utilization and accelerated access to concrete supports among low-income families.

Evidence-based health care for children: what are we missing?

With the enactment of comprehensive health reform, reimbursement for a variety of health care services will likely depend on evidence to support that provision. Understanding what constitutes "evidence" will have a profound effect on the range of clinical care provided. A too-narrow definition may have a considerable impact on pediatric care in particular: much of current child health care requires consideration of a broader body of evidence than is usually relied upon when developing clinical guidelines. This is especially true for care that addresses behavioral and developmental problems. The current standard for evaluating evidence uses study design as a proxy for the quality of evidence; it may therefore inadvertently exclude many important findings and fail to support further relevant research. The project described here yielded a new, broader framework for evaluating clinical practice, one that should be of value to both clinicians and policymakers.

Care for children and evidence-based medicine.

Child healthcare sits between two worlds: in the past, with a focus on the prevention and treatment of infectious and chronic disease and the current more expansive view of child health and our role in child health promotion. As a result, disagreements concerning the evidence basis for our work have also arisen. Clinicians may stay on track by considering multiple sources of evidence in making clinical decisions. In doing so, it helps to consider each activity from the perspective of the child, family, and community. Screening and intervention may look for existing problems, for risk and resilience factors, and for opportunities to optimize each child's developmental potential. Integration of these various concerns underlies the art of modern practice, provides the assistance that families want, and leads to continued professional satisfaction.

Partnerships for preventing violence: a locally-led satellite training model.

Local face-to-face provider training has the benefit of enabling participants to network with people in their communities who are working on similar issues, to engage in interactive discussions, and to learn from local experts and local program examples. However, face-to-face training has considerable costs (labor and expense) and provides limited exposure to national experts. In recent years, technology has allowed training methods to expand to include distance learning methods (satellite and web-based). The newer methods can decrease per-person training costs, provide exposure to national experts, and result in wide dissemination of information. Yet these distance learning methods often limit the ability of participants to interact and network with each other and substantially reduce opportunities to apply the learning objectives to local circumstances. To maximize the benefits of both models, the Harvard School of Public Health, the Prevention Institute, and the Education Development Center developed, implemented, and evaluated Partnerships for Preventing Violence (PPV), an innovative six-part satellite training series on the public health approach to preventing youth violence. Using a unique hybrid methodology that combines satellite training with local, face-to-face facilitation by trained experts, PPV trained over 13,000 people, generated youth violence prevention activities across the country, and created a national cadre of youth violence prevention leaders.

A Delphi approach to reach consensus on primary care guidelines regarding youth violence prevention.

OBJECTIVE: Anticipatory guidance is a cornerstone of modern pediatric practice. In recognition of its importance for child well being, injury prevention counseling is a standard element of that guidance. Over the last 20 years, there has been growing recognition that intentional injury or violence is one of the leading causes of morbidity and mortality among youth. The US Surgeon General identified youth violence as a major public health issue and a top priority. Yet, only recently has the scope of injury prevention counseling been expanded to include violence. Pediatric health care providers agree that youth violence-prevention counseling should be provided, yet the number of topics available, the already lengthy list of other anticipatory guidance topics to be covered, developmental considerations, and the evidence base make the selection of an agreed-on set a considerable challenge. The purpose of this study was to systematically identify and prioritize specific counseling topics in violence prevention that could be integrated into anticipatory guidance best practice. DESIGN: A modified electronic Delphi process was used to gain consensus among 50 national multidisciplinary violence-prevention experts. Participants were unaware of other participants' identities. METHODS: The process consisted of 4 serial rounds of inquiry beginning with a broad open-ended format for the generation of anticipatory guidance and screening topics across 5 age groups (infant, toddler, school age, adolescent, and all ages). Each subsequent round narrowed the list of topics toward the development of a manageable set of essential topics for screening and counseling about positive youth development and violence prevention. RESULTS: Forty-seven unique topics were identified, spanning birth to age 21 years. Topics cover 4 broad categories (building blocks): physical safety, parent centered, child centered, and community connection. Participants placed topics into their developmentally appropriate visit-based schedule and made suggestions for an appropriate topic reinforcement schedule. The resulting schedule provides topics for introduction and reinforcement at each visit. CONCLUSIONS: The Delphi technique proved a useful approach for accessing expert opinion, for analyzing and synthesizing results, for achieving consensus, and for setting priorities among the numerous anticipatory guidance and assessment topics relevant for raising resilient, violence-free youth.

Anticipatory guidance and violence prevention: results from family and pediatrician focus groups.

OBJECTIVES: Anticipatory guidance is a cornerstone of modern pediatric practice. Recent American Academy of Pediatrics policies related to violence prevention, notably those that advocate firearms safety and the use of alternatives to corporal punishment, seem to be discrepant with common parenting practices. To develop more effective anticipatory guidance, we sought the opinions of parents and pediatricians on how best to communicate these messages. DESIGN: Focus groups were conducted to elicit parent and provider opinions. SUBJECTS: Forty-nine parents participated in a total of 9 90-minute focus groups that were held in 3 cities. Twenty-six pediatricians participated in 3 focus groups that were held at a single national meeting. PROCEDURES: Participants were read summaries of current American Academy of Pediatrics policies and led through a systematic discussion of how these policies might best be communicated. The group discussions were audiotaped, transcribed, and analyzed. Common themes heard in multiple groups are reported. RESULTS: Parents provided specific feedback about corporal punishment and firearms and also raised a number of general issues. Pediatricians reported that anticipatory guidance was important to them but cited cultural and reimbursement issues as barriers to practice. They also reported the need for additional training and support to make anticipatory guidance more effective. DISCUSSION: Focus groups provide insight into doctor-patient communications and can inform efforts to improve primary prevention in the clinical setting. Anticipatory guidance that consists of authoritative useful information, offered in a supportive manner that communicates respect for parental decision-making, may be effective in improving parenting practices.