Suicidal behavior risks during adolescent pregnancy in a low-resource setting: A qualitative study.

BACKGROUND: Suicide is one of the most common causes of death among female adolescents. A greater risk is seen among adolescent mothers who become pregnant outside marriage and consider suicide as the solution to unresolved problems. We aimed to investigate the factors associated with suicidal behavior among adolescent pregnant mothers in Kenya. METHODS: A total of 27 Focus Group Discussions (FGDs) and 8 Key Informant Interviews (KIIs) were conducted in a rural setting (Makueni County) in Kenya. The study participants consisted of formal health care workers and informal health care providers (traditional birth attendants and community health workers), adolescent and adult pregnant and post-natal (up to six weeks post-delivery) women including first-time adolescent mothers, and caregivers (husbands and/or mothers-in-law of pregnant women) and local key opinion leaders. The qualitative data was analyzed using Qualitative Solution for Research (QSR) NVivo version 10. RESULTS: Five themes associated with suicidal behavior risk among adolescent mothers emerged from this study. These included: (i) poverty, (ii) intimate partner violence (IPV), (iii) family rejection, (iv) social isolation and stigma from the community, and (v) chronic physical illnesses. Low economic status was associated with hopelessness and suicidal ideation. IPV was related to drug abuse (especially alcohol) by the male partner, predisposing the adolescent mothers to suicidal ideation. Rejection by parents and isolation by peers at school; and diagnosis of a chronic illness such as HIV/AIDS were other contributing factors to suicidal behavior in adolescent mothers. CONCLUSION: Improved social relations, economic and health circumstances of adolescent mothers can lead to reduction of suicidal behaviour. Therefore, concerted efforts by stakeholders including family members, community leaders, health care workers and policy makers should explore ways of addressing IPV, economic empowerment and access to youth friendly health care centers for chronic physical illnesses. Prevention strategies should include monitoring for suicidal behavior risks during pregnancy in both community and health care settings. Additionally, utilizing lay workers in conducting dialogue discussions and early screening could address some of the risk factors and reduce pregnancy- related suicide mortality in LMICs.

Integrated Care Models and Child Health: A Meta-analysis.

CONTEXT: Integrated care models may improve health care for children and young people (CYP) with ongoing conditions. OBJECTIVE: To assess the effects of integrated care on child health, health service use, health care quality, school absenteeism, and costs for CYP with ongoing conditions. DATA SOURCES: Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library databases (1996-2018). STUDY SELECTION: Inclusion criteria consisted of (1) randomized controlled trials, (2) evaluating an integrated care intervention, (3) for CYP (0-18 years) with an ongoing health condition, and (4) including at least 1 health-related outcome. DATA EXTRACTION: Descriptive data were synthesized. Data for quality of life (QoL) and emergency department (ED) visits allowed meta-analyses to explore the effects of integrated care compared to usual care. RESULTS: Twenty-three trials were identified, describing 18 interventions. Compared with usual care, integrated care reported greater cost savings (3/4 studies). Meta-analyses found that integrated care improved QoL over usual care (standard mean difference = 0.24; 95% confidence interval = 0.03-0.44; P = .02), but no significant difference was found between groups for ED visits (odds ratio = 0.88; 95% confidence interval = 0.57-1.37; P = .57). LIMITATIONS: Included studies had variable quality of intervention, trial design, and reporting. Randomized controlled trials only were included, but valuable data from other study designs may exist. CONCLUSIONS: Integrated care for CYP with ongoing conditions may deliver improved QoL and cost savings. The effects of integrated care on outcomes including ED visits is unclear.

Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels.

Optimal care for children and adolescents with type 1 diabetes is well described in guidelines, such as those of the International Society for Pediatric and Adolescent Diabetes. High-income countries can usually provide this, but the cost of this care is generally prohibitive for lower-income countries. Indeed, in most of these countries, very little care is provided by government health systems, resulting in high mortality, and high complications rates in those who do survive. As lower-income countries work toward establishing guidelines-based care, it is helpful to describe the levels of care that are potentially affordable, cost-effective, and result in substantially improved clinical outcomes. We have developed a levels of care concept with three tiers: "minimal care," "intermediate care," and "comprehensive (guidelines-based) care." Each tier contains levels, which describe insulin and blood glucose monitoring regimens, requirements for hemoglobin A1c (HbA1c) testing, complications screening, diabetes education, and multidisciplinary care. The literature provides various examples at each tier, including from countries where the life for a child and the changing diabetes in children programs have assisted local diabetes centres to introduce intermediate care. Intra-clinic mean HbA1c levels range from 12.0% to 14.0% (108-130 mmol/mol) for the most basic level of minimal care, 8.0% to 9.5% (64-80 mmol/mol) for intermediate care, and 6.9% to 8.5% (52-69 mmol/mol) for comprehensive care. Countries with sufficient resources should provide comprehensive care, working to ensure that it is accessible by all in need, and that resulting HbA1c levels correspond with international recommendations. All other countries should provide Intermediate care, while working toward the provision of comprehensive care.

Sexuality education: emerging trends in evidence and practice.

The International Conference on Population and Development and related resolutions have repeatedly called on governments to provide adolescents and young people with comprehensive sexuality education (CSE). Drawing from these documents, reviews and meta-analyses of program evaluations, and situation analyses, this article summarizes the elements, effectiveness, quality, and country-level coverage of CSE. Throughout, it highlights the matter of a gender and rights perspective in CSE. It presents the policy and evidence-based rationales for emphasizing gender, power, and rights within programs--including citing an analysis finding that such an approach has a greater likelihood of reducing rates of sexually transmitted infections and unintended pregnancy--and notes a recent shift toward this approach. It discusses the logic of an "empowerment approach to CSE" that seeks to empower young people--especially girls and other marginalized young people--to see themselves and others as equal members in their relationships, able to protect their own health, and as individuals capable of engaging as active participants in society.

Invited commentary: broadening the evidence for adolescent sexual and reproductive health and education in the United States.

Scientific research has made major contributions to adolescent health by providing insights into factors that influence it and by defining ways to improve it. However, US adolescent sexual and reproductive health policies-particularly sexuality health education policies and programs-have not benefited from the full scope of scientific understanding. From 1998 to 2009, federal funding for sexuality education focused almost exclusively on ineffective and scientifically inaccurate abstinence-only-until-marriage (AOUM) programs. Since 2010, the largest source of federal funding for sexual health education has been the "tier 1" funding of the Office of Adolescent Health's Teen Pregnancy Prevention Initiative. To be eligible for such funds, public and private entities must choose from a list of 35 programs that have been designated as "evidence-based" interventions (EBIs), determined based on their effectiveness at preventing teen pregnancies, reducing sexually transmitted infections, or reducing rates of sexual risk behaviors (i.e., sexual activity, contraceptive use, or number of partners). Although the transition from primarily AOUM to EBI is important progress, this definition of evidence is narrow and ignores factors known to play key roles in adolescent sexual and reproductive health. Important bodies of evidence are not treated as part of the essential evidence base, including research on lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth; gender; and economic inequalities and health. These bodies of evidence underscore the need for sexual health education to approach adolescent sexuality holistically, to be inclusive of all youth, and to address and mitigate the impact of structural inequities. We provide recommendations to improve US sexual health education and to strengthen the translation of science into programs and policy.

Healthcare utilization and expenditure analysis between individuals with intellectual disabilities and the general population in Taiwan: a population-based nationwide child and adolescent study.

This study examines differences in outpatient-visit frequency and medical expenditures between (1) children and adolescents in Taiwan with intellectual disabilities and (2) children and adolescents in Taiwan's general population. A cross-sectional study was conducted to analyze data from 2007 provided by Taiwan's National Health Insurance program. A total of 236,045 beneficiaries younger than 19 years made use of outpatient services; among them, 35,802 had a principal diagnosis of mental retardation (intellectual disability). The average number of ambulatory visits was 14.9 ± 12.4, which is much higher than in the United States and other developed countries. The mean number of annual visits of the individuals with intellectual disabilities was significantly higher than that of the general population in Taiwan (20.1 ± 20.0 vs. 14.0 ± 12.2); age, gender, urbanization level of residential area, and copayment status affected outpatient visit frequency. The mean annual outpatient costs were NTD6371.3 ± NTD11989.1 for the general population and NTD19724.9 ± NTD40469.9 for those with intellectual disabilities (US $1 equals approximately NTD30). Age, gender, urbanization level of residential area, and copayment status were the determinants that accounted for this difference in cost. Children and adolescents with intellectual disabilities had higher use rates of rehabilitative and psychiatric services than the general population. We conclude that individuals with intellectual disabilities had higher demands than the general population for healthcare services, especially for rehabilitative and psychiatric services.

Massachusetts' Pediatric Palliative Care Network: successful implementation of a novel state-funded pediatric palliative care program.

BACKGROUND: U.S. children with life-limiting illness face barriers to accessing palliative care. In 2006, Massachusetts signed into law a statute providing for the creation and funding of the Pediatric Palliative Care Network (PPCN). This innovative, exclusively state-funded program provides comprehensive direct and consultative community-based pediatric palliative care services including: (1) pain and symptom management, (2) case management and assessment, (3) social services, counseling, and bereavement services, (4) volunteer support services, (5) respite services, and (6) complementary therapies. Provision of care is through a network of state-licensed hospice programs, and an array of professional and volunteer services. OBJECTIVE: To describe Massachusetts' experience in implementing a novel pediatric palliative care program. DESIGN: Enrollment and service trends were identified using Massachusetts Department of Public Health administrative data. Responses to a written family satisfaction survey provided to each family enrolled on PPCN are summarized. RESULTS: In fiscal year 2010, PPCN partnered with 11 hospice programs to provide services to 227 children with life-limiting illness. A total of $680,850 (86.7%) of state funding went to direct contract funds for hospices. Admitting diagnoses included cancer (30%), chromosomal abnormalities (17%), neurodegenerative disorders (15%), and other (38%). There were 11 deaths, 100% of which occurred in the family's requested location. Median length of stay on service prior to death was 233 days. Families most commonly implemented psychosocial and case management services, followed by complementary therapies, and volunteer services. CONCLUSIONS: Successful implementation of a statewide pediatric palliative care program as modeled in Massachusetts is highly feasible at relatively low cost.

School-linked sexual health services for young people (SSHYP): a survey and systematic review concerning current models, effectiveness, cost-effectiveness and research opportunities.

BACKGROUND: Report based on a service-mapping study and a systematic review concerning sexual health services for young people, either based in or closely linked to schools. OBJECTIVES: To identify current forms of school-based sexual health services (SBSHS) and school-linked sexual health services (SLSHS) in the UK, review and synthesise existing evidence from qualitative and quantitative studies concerning the effectiveness, acceptability and cost-effectiveness of these types of service and to identify potential areas for further research. DATA SOURCES: Electronic databases were searched from 1985 onwards. For published material: the Cochrane Library (1991-), MEDLINE, PREMEDLINE (2007-), CINAHL, EMBASE, AMED, ASSIA (1987-), IBSS, ERIC, PsycINFO, Science Citation Index (SCI) and Social Sciences Citation Index. For unpublished material and grey literature: the Social Care Institute of Excellence Research Register; the National Research Register (1997-), ReFeR; Index to Theses, and HMIC. REVIEW METHODS: A service-mapping questionnaire was circulated to school nurses in all parts of the UK, and semistructured telephone interviews with service coordinators in NHS and local authority (LA) roles were conducted. An evidence synthesis was performed based on a systematic review of the quantitative evidence about service effectiveness, qualitative evidence about user and professional views and a mixed-methods synthesis. A proof-of-concept model for assessing cost-effectiveness was drawn up. RESULTS: Three broad types of UK sexual health service provision were identified. Firstly, SBSHS staffed by school nurses, offering 'minimal' or 'basic' levels of service. Secondly, SBSHS and SLSHS staffed by a multiprofessional team, but not medical practitioners, offering 'basic' or 'intermediate' levels of service. Thirdly, SBSHS and SLSHS staffed by a multiprofessional team, including medical practitioners offering 'intermediate' or 'comprehensive' levels of service. The systematic review showed that SBSHS are not associated with higher rates of sexual activity among young people, nor with an earlier age of first intercourse. There was evidence to show positive effects in terms of reductions in births to teenage mothers, and in chlamydial infection rates among young men, although this evidence coming primarily from the USA. Therefore, the findings need to be tested in relation to UK-based services. Also evidence to suggest that broad-based, holistic service models, not restricted to sexual health, offer the strongest basis for protecting young people's privacy and confidentiality, countering perceived stigmatisation, offering the most comprehensive range of products and services, and maximising service uptake. Findings from the mapping study also indicate that broad-based services, which include medical practitioner input within a multiprofessional team, meet the stated preferences of staff and of young people most clearly. Partnership-based developments of this kind also conform to the broad policy principles embodied in the Every Child Matters framework in the UK and allied policy initiatives. However, neither these service models nor narrower ones have been rigorously evaluated in terms of their impact on the key outcomes of conception rates and sexually transmitted infection (STI) rates, in the UK or in other countries. Therefore, appropriate data were not found to support cost-effectiveness modelling. LIMITATIONS: Low response rate to the questionnaire. Scotland, Wales and Northern Ireland were under-represented. Also, the distinction made in the questionnaire between 'general health' and 'sexual health' services did not prove robust. CONCLUSIONS: There is no single, dominant service model in the UK. The systematic review demonstrated that the evidence base for these services remains limited and uneven, and draws largely on US studies. Qualitative research is needed to develop robust process and outcome indicators for the evaluation of SLSHS/SBSHS in the UK. These indicators could then be used both in local evaluations, and in large, longitudinal studies of service effectiveness and cost-effectiveness. Future research should examine the impact of the differing types of services currently evolving in the UK, encompassing school-based and school-linked models, as well as models with and without medical practitioner involvement.

The impact of publicly funded managed care on adolescent substance abuse treatment outcomes.

This study compares the 12-month changes in substance use following admission to substance abuse treatment in Massachusetts between adolescents enrolled in Medicaid managed care and other publicly funded adolescents. Two hundred and fifty-five adolescents were interviewed as they entered substance abuse treatment and at 6 and 12 month follow-ups. Medicaid enrollment data were used to determine the managed care enrollment status. One hundred forty two (56%) adolescents were in the managed care group and 113 (44%) comprise the comparison group. Substance use outcomes include a count of negative consequences of substance use, days of alcohol use, days of cannabis use, and days of any substance use in the previous 30 days. Repeated measures analysis of covariance (ANCOVA) was used to assess change with time of measurement and managed care status as main effects and the interaction of time and managed care included to measure differences between the groups over time. Although several changes across time were detected for all four outcomes, we found no evidence of an impact of managed care for any of the outcomes. The results of our study do not support the fears that behavioral managed care, by imposing limits on services provided, would substantially reduce the effectiveness of substance abuse treatment for adolescents. At the same time, the results do not support those who believe that the continuity of care and improved resource utilization claimed for managed care would improve outcomes.

Chaplain contacts improve treatment outcomes in residential treatment programs for delinquent adolescents.

This is a report of a study of 828 delinquent adolescents who completed behavioral treatment during 1995, 1996, 1997 in Holy Cross Children's Services programs. The research focused on a measure of chaplain contact time with each youth, and three outcome variables: "planned release" (program completion), living situation at 12 months after discharge, and a calculated cost of care for the 12 month graduates. The findings include statistically significant correlations between chaplain time and all three preferred outcome measures. The results were significant when age, number of prior incarcerations and religiosity variables were controlled for in a regression analysis. When the costs of aftercare for the graduates were computed, the average cost-of care-per-day of the no-Chaplain-contact graduates was significantly higher than that of the high-contact group. Based on the findings, the author suggests that chaplain involvement in the behavioral treatment of delinquent adolescents improves outcomes and is cost effective.

Baltimore's consumer ombudsman and assistance program: an emerging public health service in Medicaid Managed Care.

OBJECTIVES: To present Baltimore City Health Department's (BCHD) experience in developing and operating an ombudsprogram for Maryland's Medicaid Managed Care HealthChoice Program as an innovative public health response to its MCH Title V assurance functions. METHODS: This paper presents a case study that 1) describes Baltimore City's Consumer Ombudsman and Assistance Program (COAP) in terms of development, function, structure, and resources; 2) provides a summary of its first 30 months' experiences, both quantitatively and qualitatively; and 3) describes COAP's successes, value, and limitations with respect to its three essential roles--a) conflict resolution for individuals, b) education for consumers, providers and advocates, and c) catalyst for quality improvement. OUTCOMES: Over 1300 cases (involving enrollment, access, billing, and treatment issues) were referred to COAP by the State's Complaint Resolution Section during the first 2 1/2 years of HealthChoice. Ombudsman interventions resulted in conflict resolution for enrollees using a continuum of education, mediation and advocacy, and in generating systematic data for systems change through collaboration with state and community public health, managed care organization, provider, consumer, and advocacy officials and groups. CONCLUSIONS: Public health ombudsprograms can effectively assist and educate enrollees; and provide concurrent, or real-time, information for consumer, provider, health plan, and advocacy groups, as well as public policymakers and legislators to better inform systems improvement and innovation. The community-based ombudsman role is an effective mechanism to ensure appropriate care for MCH populations and others with special needs. Such efforts can be funded by federal/state Medicaid administrative funds and are a sound investment in assuring access to comprehensive care for vulnerable populations.

Preventive dental care of children and adolescents in the 1990s: Denmark, Iceland, Norway, and Sweden.

This article describes the provision of preventive care for children and adolescents in Denmark, Iceland, Norway, and Sweden in the 1990s. It includes information on personnel giving preventive care, administration of the dental care system, strategies and methods used for prevention, and resources allocated for preventive dental care. In all these countries comprehensive and systematic dental care, subsidized or free of charge, has been instituted for children and adolescents. However, comparisons between the countries show significant differences in the organization of the dental care for children, the time used for preventive care, the recall routines, and the implementation of risk-based and population-based preventive strategies. The relative importance of different caries-prevention methods (fluorides, hygiene, and diet) reported by the clinicians varied between Denmark, Iceland, Norway, and Sweden. While variation poses rather than answers questions concerning effectiveness, available data provide evidence of differences in the input of resources. Unless the dental profession addresses the issue of effectiveness of preventive dental care, politicians and administrators in a cost-containment context will easily conclude that least is best.

Managed care organizations and public health: exploring collaboration on adolescent immunizations.

Managed care organizations (MCOs) joined local and state public health agencies in a pilot effort to improve hepatitis B immunization rates of adolescents in an urban and a suburban/rural school district. The pilot also explored issues inherent in public and private collaboration on population health improvement. Local public health agencies provided links to schools in their communities, took the lead in implementing school-based immunization programs, and provided health education materials. MCOs contributed financial support necessary for the project. The final cost per fully vaccinated student, not taking into account the work group's planning and coordination time, was little more than the catalog price of the vaccine alone. Managed care organizations face challenges that complicate their participation and funding of school-based vaccinations: 1) Limited data on health plans of participating students complicate allocation of costs to each MCO; 2) Double-paying occurs for MCOs paying clinics a monthly, per-member rate that already includes adolescent immunizations; 3) When schools provide adolescent immunizations, MCOs lose the "hook" that draws adolescents to clinics for comprehensive health services. When self-consenting is permitted, schools can achieve a high consent and completion rates for multi-dose adolescent immunizations such as hepatitis B. At the same time, MCOs have the responsibility to provide members with comprehensive care and should continue to examine both internal modifications and external partnerships as opportunities to improve their services to adolescents.

[Quality assurance in child and adolescent health care]. / Qualitätssicherung im Jugendgesundheitsdienst.

Quality assurance will be an important challenge not only in the private medical sector, but also in Public Health Services of Germany. In this contribution the basic principles of quality control are explained in a concise form: definition of quality, standard levels in quality assurance and control, evaluation and realisation. As far as possible some practical examples derived from the school and youth health services are explained. They can be modified to apply to other departments of Public Health Services.