The living environment and children's fears following the Indonesian tsunami.

The tsunami that struck South-east Asia on 26 December 2004 left more than 500,000 people in Aceh, Indonesia, homeless and displaced to temporary barracks and other communities. This study examines the associations between prolonged habitation in barracks and the nature of fears reported by school-age children and adolescents. In mid-2007, 30 months after the tsunami, the authors interviewed 155 child and parent dyads. Logistic regression analysis was used to compare the fears reported by children and adolescents living in barracks with those reported by their peers who were living in villages. After adjusting for demographic factors and tsunami exposure, the data reveals that children and adolescents living in barracks were three times more likely than those living in villages to report tsunami-related fears. The study demonstrates that continued residence in barracks 30 months after the tsunami is associated with higher rates of reporting tsunami-related fears, suggesting that barracks habitation has had a significant impact on the psychological experience of children and adolescents since the tsunami.

Global Gaps in Training Opportunities for Pediatricians and Pediatric Subspecialists.

OBJECTIVE: A comprehensive, well-trained pediatric workforce is needed to ensure high-quality child health interventions around the globe. Further understanding of pediatric workforce training capacity would assist planning at the global and country level. The purpose of this study was to better understand the availability and process of training programs for pediatricians and pediatric subspecialists worldwide, as well as in-country presence of subspecialists. METHODS: A survey was developed and distributed by e-mail to national pediatric leaders across the globe. The survey asked about the number of pediatric training programs, duration and logistics of training, and whether practicing pediatric subspecialists and subspecialty training programs were available in their country. RESULTS: We received responses from 121 of the 166 countries contacted (73%). Of these, 108 countries reported the presence of one or more general pediatric postgraduate training programs, ranging from 1 to 500 programs per country. The number of training programs did not vary significantly by gross domestic product but did vary by region, with the fewest in Africa (P < .001). Most countries identified national guidelines for training (82% of countries) and accreditation (84% of countries). Availability of pediatric subspecialists varied significantly by income and region, from no subspecialties available in 4 countries to all 26 queried subspecialties available in 17 countries. Neonatology was most common, available in 88% of countries. Subspecialty training programs were less available overall, significantly correlating with country income. CONCLUSION: Education for general pediatrics and pediatric subspecialties is quite limited in many of the countries surveyed, particularly in Africa. The creation of additional educational capacity is a critical issue challenging the adequate provision of pediatrics and pediatric subspecialty services.

Lessons from pediatrics residency program directors' experiences with work hour limitations in New York State.

PURPOSE: To evaluate the impact of residency work hour limitations on pediatrics residency programs in New York State, and to learn lessons that can be used nationally with the implementation of the Accreditation Council of Graduate Medical Education's similar rules. METHOD: A three-page questionnaire was mailed to all pediatrics residency program directors in New York. The questionnaire assessed methods used to accommodate the work hour limitations and perceptions of the limitations' effects. RESULTS: Twenty-one program directors responded (68%). Only large programs used night floats and night teams to meet work hour requirements. Programs of all sizes and in all settings used cross coverage and sent residents home immediately post call. About half of the programs hired additional nonresident staff, usually nurse practitioners, physician assistants, and/or attendings. The most frequently reported effects were decreases in the amount of time residents spent in inpatient settings, patient continuity in inpatient settings, flexibility of residents' scheduling, and increased logistical work needed to maintain continuity clinic. A summary of advice to other program directors was "be creative" and "be flexible." CONCLUSIONS: New York's pediatrics residency programs used a variety of mechanisms to meet work hour restrictions. Smaller programs had fewer methods available to them to meet such restrictions. Although the logistical work needed to maintain continuity clinic increased greatly, continuity and outpatient settings themselves were not greatly affected by work hour limitations. Inpatient settings were more affected and experienced much more in the way of change.

Educating the next generation of pediatricians in urban health care: the Anne E. Dyson Community Pediatrics Training Initiative.

To improve the health of children who are exposed to urban health risks, there has been a national recognition of the need for better models of training pediatricians. In 2000, in response to this need, the Dyson Foundation launched a new residents-training model that focuses on community health and advocacy, The Anne E. Dyson Community Pediatrics Training Initiative (the Initiative). The Initiative is made up of 12 programs at ten sites, which are working in their communities to improve the health of the children. At its core are five objectives: to equip residents with tools and knowledge to provide community-based health care, to make use of community resources so that residents learn to practice as medical home providers, to engage residents in the communities in which they work, to develop meaningful partnerships between departments of pediatrics and their communities, and to enhance pediatrics training through interdisciplinary collaborations among schools and departments. Curricular approaches at the participating sites differ slightly, but all have explicitly incorporated teaching community pediatrics into their standard rotations and continuity clinics. The authors showcase the programs of the Initiative and explore how the programs have sought buy-in from their parent institutions, faculty, residents, and communities.

Variations in state-level definitions: children with special health care needs.

UNLABELLED: Multiple agencies at the federal and state level provide for children with special health care needs (CSHCN), with variation in eligibility criteria. Epidemiological studies show that 3.8%-32% of children could be classified as children with special health care needs, depending on the definition and method of determination used. OBJECTIVES: To determine the extent of variation between definitions used and funding by Supplemental Security Income (SSI), Title V, and Medicaid for CSHCN. METHODS: Statistics on children receiving SSI and the amount of funding were obtained from the SSI website. This was compared to information on Title V children from the Maternal and Child Health Bureau (MCHB) website and eligibility definitions published by the Institute of Child Health Policy in Gainesville, Florida. Medicaid definitions were obtained through interviews with state Medicaid agencies and confirmed with state regulations. RESULTS: The population enrolled in SSI has varied with alterations in eligibility criteria. The number of children enrolled in SSI and the amount of funding per child in each state correlate with the state poverty rate (r=0.56, p<0.0001; r=0.44, p<0.001). Enrollment in Title V does not correlate with state poverty rates (r=0.16, p=0.25). Title V definitions vary widely among states, but there was no correlation between the number of children served or amount of funding per child and the type of definition used (Z=-0.12, p=0.91; Z=-0.59, p=0.55). State Medicaid agencies rarely define CSHCN. CONCLUSIONS: There is significant variation in definitions used by agencies serving CSHCN. Agencies need to be more explicit with eligibility criteria so the definitions are logical to those making referrals for services.

A new, experiential curriculum in child advocacy for pediatric residents.

OBJECTIVE: To design, implement, and evaluate an experiential child advocacy curriculum for pediatric residents. DESIGN: Pilot study including before-after 2-group trial of an educational intervention and a qualitative component. SETTING: A large, hospital-based, urban resident continuity clinic. PARTICIPANTS: General pediatrics residents (N = 29 [PGY: 1-4]). INTERVENTION: Residents and faculty designed a longitudinal curriculum in child advocacy for the continuity clinic, which included community-based and legislative experiences for individual residents as well as clinic-based group activities. Residents reported their experiences to their clinic group at weekly preclinic conferences. In addition, residents presented posters at their year-end residency retreat and wrote grants to fund community projects based on their original findings. EVALUATION: We used a quantitative assessment of child advocacy knowledge, attitudes, skills, and self-reported practices, which residents completed pre- and postintervention (2 clinics) or, for comparison residents, at the beginning and end of the academic year (3 clinics). In addition, we conducted focus-group discussions with residents in the 2 intervention groups to explore unanticipated responses to the new curriculum. RESULTS: Residents who received the intervention (n = 13) had a greater increase in advocacy knowledge (2.62 vs 0.19, P =.005), ability to identify community resources (0.62 vs 0.16, P =.03), self-reported advocacy skills (2.0 vs -0.21, P =.002), and perceived value of advocacy training (0.31 vs -0.19, P =.03) compared with residents who did not (n = 16). In focus groups, intervention residents (n = 17) reported being surprised by community groups' and legislators' responsiveness to resident inquiries, and they expressed enhanced confidence in engaging these groups in dialogue about child policy issues. CONCLUSIONS: A longitudinal continuity clinic-based curriculum in child advocacy had significant positive impact on pediatric residents.

The doctor's dilemma: challenges for the primary care physician caring for the child with special health care needs.

OBJECTIVE: To identify barriers to providing quality primary care to children with special health care needs (CSHCN). METHODOLOGY: Descriptive cross-sectional needs assessment of primary care physicians caring for CSHCN. The population consists of 30 physicians from 2 health centers and 4 private offices participating in an intervention study designed to enhance primary care for CSHCN and 20 physicians from comparable sites (2 health centers, 5 private offices). An 86-item questionnaire was administered to participants. RESULTS: Among these physicians who care for large numbers of CSHCN, over 70% were satisfied with specialist care, emergency room, and hospital care. By contrast, fewer than 50% reported satisfaction with mental health services, information available for families, access to case managers, and resources for transition-to-adult services. Seventy-one percent reported that compensation systems affected care, and more than half the physicians reported needing more time or staff to provide optimal care for CSHCN. CONCLUSIONS: Experienced physicians providing primary care for large numbers of CSHCN report that their care is adversely affected by compensation systems. There is extensive dissatisfaction with the availability of mental health services, access to community resources, transition services, and availability of written information for families.

Health inequity in children and youth with chronic health conditions.

BACKGROUND: Over the last decades, there have been great advances in health care delivered to children with chronic conditions, but not all children have benefitted equally from them. OBJECTIVES: To describe health inequities experienced by children with chronic health conditions. METHODS: We performed a literature review of English-language studies identified from the Medline, Centers for Disease Control and Prevention, National Cancer Institute, and Cystic Fibrosis Foundation Web sites that were published between January 1985 and May 2009, included children aged 0 to 18 years, and contained the key words "incidence," "prevalence," "survival," "mortality," or "disparity" in the title or abstract for the following health conditions: acute leukemia, asthma, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders, cerebral palsy, cystic fibrosis, diabetes mellitus, Down syndrome, HIV/AIDS, major congenital heart defects, major depressive disorder, sickle cell anemia, spina bifida, and traumatic brain injury. RESULTS: Black children had higher rates of cerebral palsy and HIV/AIDS, were less likely to be diagnosed with ADHD, had more emergency department visits, hospitalizations, and had higher mortality rates associated with asthma; and survived less often with Down syndrome, type 1 diabetes, and traumatic brain injury when compared with white children. Hispanic children had higher rates of spina bifida from Mexico-born mothers, had higher rates of HIV/AIDS and depression, were less likely to be diagnosed with ADHD, had poorer glycemic control with type 1 diabetes, and survived less often with acute leukemia compared with white children. CONCLUSIONS: Serious racial and ethnic health and health care inequities persist for children with chronic health conditions.

Paediatric experiences with work-hour limitations.

OBJECTIVES: To evaluate the perceived impact of work-hour limitations on paediatric residency training programmes and to determine the various strategies used to accommodate these restrictions. METHODS: A three-page pre-tested survey was administered to programme directors at the 2004 Association of Paediatric Programme Directors meeting. The impact of work-hours was evaluated with Likert-type questions and the methods used to meet work-hour requirements were compared between large programmes (>or=30 residents) and small programmes. RESULTS: Surveys were received from 53 programme directors. The majority responded that work-hour limitations negatively impacted inpatient continuity, time for education, schedule flexibility and attending staff satisfaction. Supervision by attending staff was the only aspect to significantly improve. Perceived resident satisfaction was neutral. To accommodate work-hour limitations, 64% of programmes increased clinical responsibility to existing non-resident staff, 36% hired more non-resident staff and 17% increased the number of residents. Only one programme hired additional non-clinical staff. Large programmes were more likely to use more total methods on the inpatient wards (P < 0.01) and in the intensive care units (P < 0.05) to accommodate work-hour limitations. CONCLUSIONS: Programme directors perceived a negative impact of work-hours on most aspects of training without a perceived difference in resident satisfaction. While a variety of methods are used to accommodate work-hour limitations, programmes are not widely utilizing non-clinical staff to alleviate clerical burdens.

Immunizations in children with special health care needs in a medical home model of care.

OBJECTIVE: To assess whether a model of care with augmented services within an existing medical home could improve immunization rates for Children with Special Health Care Needs (CSHCN) and to evaluate the influence of family and practice characteristics on these children's immunization rates. METHOD: Participants were six general pediatric practices, CSHCN, and their families. Enhancements were added to the medical home for CSHCN, including additional nurse practitioner time. A prospective survey and chart review of volunteer families was made in 1998 repeating the chart review in 2000. RESULTS: The immunization rates of CSHCN in the practices before the intervention was 83.4% for DTaP, polio and MMR and 80% if HIB and HepB were added. The intervention did not improve these already high rates. In regression models, children with late onset disorders were more likely NOT to be up-to-date (UTD) by 2 years of age (OR 3.29). CSHCN cared for by non-birth parents and CSHCN whose family incomes were greater than $40,000 per year were also more likely NOT to be UTD (OR 3.81, 2.75 respectively) as were patients of providers not satisfied with any aspect of serving patients (OR 3.29). CONCLUSIONS: In these practices already committed to a medical home model of care for CSHCN, immunization rates were at or above state and national averages before any intervention took place. Some groups of patients among these CSHCN were more likely to be delayed with immunizations, including those with late onset disorders and those with high family incomes.

Pediatricians' perspectives regarding community child health: training, involvement, and expectations according to age.

OBJECTIVE: There are increasing opportunities for pediatricians to promote children's health through community involvement during and after residency training. Little is known about whether younger relative to established pediatricians have different experiences regarding community activities. In this study we examined whether pediatricians' training, perspectives, and involvement in community activities vary by age. METHODS: Eight hundred seventy-six pediatricians participated in a national, random-sample, mailed periodic survey of US members of the American Academy of Pediatrics in 2004 (response rate: 58%). Chi2 statistics and median tests were used to measure associations of age (< or = 34, 35-39, 40-50, and > or = 51 years) with training, perspectives, and involvement. RESULTS: Younger pediatricians reported more training in community child health during and before residency but were less likely to be involved currently (37.9% for < or = 34 years, 44.4% for 35-39 years, 46.2% for 40-50 years, 48.3% for > or = 51 years). They were more likely to report that their current involvement was too little versus just right or too much (81.3%, 73.5%, 60.7%, and 47.1%, respectively). Younger pediatricians were more willing to spend > or = 1 hour/month on community child health activities (95.0%, 91.2%, 89.7%, and 85.4%, respectively). Younger versus older pediatricians were more likely to sense moderate or greater responsibility for improving children's health in their community (83.6%, 77.2%, 76.7%, and 70.2%, respectively) and expected their community work to increase during the next 5 years (80.0%, 67.5%, 59.7%, and 40.1%, respectively). Age findings persisted when adjusted for gender. CONCLUSIONS: Although practice constraints may limit community involvement, younger pediatricians anticipated growing participation in community activities. Longitudinal studies are needed to determine whether such expectations are realized.