Meeting the mental health needs of children and youth through integrated care: A systems and policy perspective.

The health home program established under the Affordable Care Act (2010) is derived from the medical home concept originated by the American Academy of Pediatrics in 1968 to provide a care delivery model for children with special health care needs. As applied to behavioral health, health homes or medical homes have become increasingly adult-focused models, with a primary goal of coordinating physical and behavioral health care. For children and youth with serious emotional disorders, health homes must go beyond physical and behavioral health care to connect with other child-focused sectors, such as education, child welfare, and juvenile justice. Each of these systems have a significant role in helping children meet health and developmental goals, and should be included in integrated approaches to care for children and youth. Health homes for young people should incorporate a continuum of care from health promotion to the prevention and treatment of disorders. The challenge for child- and youth-focused health homes is to integrate effective services and supports into the settings where young people naturally exist, drawing on the best evidence from mental health, physical medicine, and other fields. What may be needed is not a health home as currently conceptualized for adults, nor a traditional medical home, but a family- and child-centered coordinated care and support delivery system supported by health homes or other arrangements. This article sets out a health home framework for children and youth with serious mental health conditions and their families, examining infrastructure and service delivery issues.

Pathways to child mental health services among patients in an urban clinical setting in Egypt.

OBJECTIVE: Of the 82.6 million people living in Egypt, 31% are children under age 15. Until recently, identification and treatment of child mental health problems have not been a high priority in Middle East countries. This study examined referral patterns of children who visited a government- operated, urban, outpatient mental health clinic in Cairo and the duration of illness before psychiatric consultation was obtained. METHODS: A total of 123 patients were recruited from a child psychiatry outpatient clinic at the Institute of Psychiatry of Ain Shams University hospitals. Diagnoses were made with the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version, the Gilliam Autism Rating Scale, and the Stanford-Binet Intelligence Scale. RESULTS: For 63% of children, the most distressing symptom reported was behavioral problems. The mean ± SD duration of illness before psychiatric consultation was 3.4 ± 3.1 years. Autism, mental retardation, and nocturnal enuresis were significantly associated with delays in obtaining psychiatric consultation, as was belonging to the middle or low social class. For most patients (67%), the first contact was with either a pediatrician or a psychiatrist. For a smaller proportion (5%), the first contact was a traditional healer. Most patients were referred to the clinic by relatives (30%), followed by pediatricians (21%), school teachers (12%), and traditional healers (5%). CONCLUSIONS: Most parents first sought the advice of pediatricians for their child's mental health problem, and a substantial number consulted traditional healers. Awareness programs targeting pediatricians and elementary school teachers are urgently needed in Egypt to shorten the duration of undiagnosed illness among children.

Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries.

BACKGROUND: Countdown to 2015 tracks progress towards achievement of Millennium Development Goals (MDGs) 4 and 5, with particular emphasis on within-country inequalities. We assessed how inequalities in maternal, newborn, and child health interventions vary by intervention and country. METHODS: We reanalysed data for 12 maternal, newborn, and child health interventions from national surveys done in 54 Countdown countries between Jan 1, 2000, and Dec 31, 2008. We calculated coverage indicators for interventions according to standard definitions, and stratified them by wealth quintiles on the basis of asset indices. We assessed inequalities with two summary indices for absolute inequality and two for relative inequality. FINDINGS: Skilled birth attendant coverage was the least equitable intervention, according to all four summary indices, followed by four or more antenatal care visits. The most equitable intervention was early initation of breastfeeding. Chad, Nigeria, Somalia, Ethiopia, Laos, and Niger were the most inequitable countries for the interventions examined, followed by Madagascar, Pakistan, and India. The most equitable countries were Uzbekistan and Kyrgyzstan. Community-based interventions were more equally distributed than those delivered in health facilities. For all interventions, variability in coverage between countries was larger for the poorest than for the richest individuals. INTERPRETATION: We noted substantial variations in coverage levels between interventions and countries. The most inequitable interventions should receive attention to ensure that all social groups are reached. Interventions delivered in health facilities need specific strategies to enable the countries' poorest individuals to be reached. The most inequitable countries need additional efforts to reduce the gap between the poorest individuals and those who are more affluent. FUNDING: Bill & Melinda Gates Foundation, Norad, The World Bank.

Pathways of care-seeking during fatal infant illnesses in under-resourced South African settings.

The purpose of this study was to examine care-seeking during fatal infant illnesses in under-resourced South African settings to inform potential strategies for reducing infant mortality. We interviewed 22 caregivers of deceased infants in a rural community and 28 in an urban township. We also interviewed seven local leaders and 12 health providers to ascertain opinions about factors contributing to infant death. Despite the availability of free public health services in these settings, many caregivers utilized multiple sources of care including allopathic, indigenous and home treatments. Urban caregivers reported up to eight points of care while rural caregivers reported up to four points of care. The specific pathways taken and combinations of care varied, but many caregivers used other types of care shortly after presenting at public services, indicating dissatisfaction with the care they received. Many infants died despite caregivers' considerable efforts, pointing to critical deficiencies in the system of care serving these families. Initiatives that aim to improve assessment, management and referral practices by both allopathic and traditional providers (for example, through training and improved collaboration), and caregiver recognition of infant danger signs may reduce the high rate of infant death in these settings.

Overview of newborn hearing screening activities in Latin America.

OBJECTIVE: Ascertain the status of early hearing detection and intervention services in Latin America. METHODS: Between June and November 2007, Gallaudet University, in collaboration with the U.S. Centers for Disease Control and Prevention Early Hearing Detection and Intervention Diversity Committee, disseminated a survey to 11 Latin American countries. It included questions about newborn hearing screening (NHS) procedures, the availability of intervention services for infants with hearing loss, and challenges in identifying infants with hearing loss. In addition, a literature review was conducted to help identify the status of NHS efforts in Latin America. RESULTS: Six countries (Chile, Costa Rica, Guatemala, Mexico, Panama, and Uruguay) and one U.S. territory (Puerto Rico) responded to the survey. Responses indicated that efforts to identify infants with hearing loss vary within and across countries in Latin America. In some countries, activities have been implemented at a national level; in others, activities have been implemented at a single hospital or region within a country. Common barriers to implementation of NHS programs include a lack of funding, screening and diagnostic equipment, public awareness, and personnel qualified to work with infants and young children. CONCLUSIONS: In spite of several barriers, NHS programs have been implemented in at least some facilities and regions in Latin America. Additional efforts are needed to expand NHS activities in Latin America.

Overview of newborn hearing screening activities in Latin America / Panorama de las actividades de examen sistemático de la capacidad auditiva en recién nacidos en América Latina

OBJECTIVE: Ascertain the status of early hearing detection and intervention services in Latin America. METHODS: Between June and November 2007, Gallaudet University, in collaboration with the U.S. Centers for Disease Control and Prevention Early Hearing Detection and Intervention Diversity Committee, disseminated a survey to 11 Latin American countries. It included questions about newborn hearing screening (NHS) procedures, the availability of intervention services for infants with hearing loss, and challenges in identifying infants with hearing loss. In addition, a literature review was conducted to help identify the status of NHS efforts in Latin America. RESULTS: Six countries (Chile, Costa Rica, Guatemala, Mexico, Panama, and Uruguay) and one U.S. territory (Puerto Rico) responded to the survey. Responses indicated that efforts to identify infants with hearing loss vary within and across countries in Latin America. In some countries, activities have been implemented at a national level; in others, activities have been implemented at a single hospital or region within a country. Common barriers to implementation of NHS programs include a lack of funding, screening and diagnostic equipment, public awareness, and personnel qualified to work with infants and young children. CONCLUSIONS: In spite of several barriers, NHS programs have been implemented in at least some facilities and regions in Latin America. Additional efforts are needed to expand NHS activities in Latin America.

OBJETIVO: Evaluar la situación de los servicios de detección e intervención tempranas de problemas auditivos en América Latina. MÉTODOS: Entre junio y noviembre del 2007, la universidad Gallaudet, en colaboración con el Comité de Diversidad del Programa de Detección Auditiva e Intervención Tempranas de los Centros para el Control y la Prevención de Enfermedades de los Estados Unidos, distribuyó un cuestionario en 11 países latinoamericanos. El cuestionario incluía preguntas acerca de los procedimientos de examen sistemático de la capacidad auditiva en recién nacidos, la disponibilidad de servicios de intervención para menores de un año hipoacúsicos y los retos para detectarlos. Además, se efectuó una revisión bibliográfica para ayudar a determinar el estado de las iniciativas de examen sistemático de la audición en recién nacidos en América Latina. RESULTADOS: Respondieron a la encuesta seis países (Chile, Costa Rica, Guatemala, México, Panamá y Uruguay) y un territorio de los Estados Unidos (Puerto Rico). Las respuestas indicaron que los esfuerzos para detectar a los menores de un año hipoacúsicos varían dentro de cada país y de un país a otro en América Latina. En algunos países se han realizado actividades a nivel nacional; en otros, en un único hospital o zona del país. Los factores que con frecuencia obstaculizan la puesta en práctica de los programas de examen sistemático de la audición en recién nacidos incluyen la falta de financiamiento, de equipos de tamizaje y diagnóstico, de concientización del público y de personal capacitado para atender a menores de un año y niños pequeños. CONCLUSIONES: A pesar de que existen varios obstáculos, se han ejecutado programas de examen sistemático de la audición en recién nacidos en al menos algunos establecimientos de salud y zonas de América Latina. Se necesitan esfuerzos mayores para ampliar estas actividades en América Latina.

Tertiary paediatric obesity services in Australia.

AIM: To examine the nature and availability of paediatric obesity services in tertiary care settings across the states/territories of Australia. METHODS: Surveys were sent to all clinicians identified as offering obesity services to children and adolescents. Respondents were asked to identify other service providers in their area, who were also asked to complete the survey. RESULTS: Sixteen clinicians responded to the survey, from 20 requests. The clinicians who responded identified nine services in three of the eight states/territories of Australia. Existing services are limited to children and adolescents with severe obesity, with an average of 12 new referrals per service each month and an average waiting time of 5 months for an appointment. Most services involve a multidisciplinary approach, although the mix of staff varies considerably and emphasises nutrition rather than physical activity approaches. CONCLUSIONS: Despite the public attention devoted to paediatric obesity, tertiary services in Australia are inadequate to meet the increasing incidence and prevalence of this complex condition. The development of tertiary services as part of service delivery arrangements for paediatric obesity and its associated morbidities must become a priority within the health system.

Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania.

OBJECTIVE: To describe geographical patterns of implementation of the Integrated Management of Childhood Illness (IMCI) strategy in three countries and to assess whether the strategy was implemented in areas with the most pressing child health needs. METHODS: We conducted interviews with key informants at the national and district levels in Brazil, Peru and the United Republic of Tanzania, and an ecological study of factors associated with health worker training in IMCI. Explanatory factors included district population, distance from the capital, human development index, other socioeconomic indicators and baseline mortality rates in children younger than five years. FINDINGS: In line with recommendations by WHO, early implementation districts were characterized by proximity to the capital and suitable training sites, presence of motivated health managers and a functioning health system. In the expansion phase, IMCI tended to be adopted by other districts with similar characteristics. In Brazil, uptake by poor and small municipalities and those further away from the state capital was significantly lower. In Peru, there was no association with distance from Lima, and a non-significant trend for IMCI adoption by small and poor departments. In the United Republic of Tanzania, the only statistically significant finding was a lower uptake by remote districts. Implementation was not associated with baseline mortality levels in any country studied. CONCLUSION: Whereas clear and reasonable guidelines are provided for selection of early use districts, no criteria for promoting IMCI expansion had been issued, and areas of greatest need were not prioritized. Equity analyses based on the geographical deployment of new programmes and strategies can contribute to assessing whether they are reaching those who need them most.

International pediatric emergency care: establishment of a new specialty in a developing country.

BACKGROUND: Emergency medicine is being established as a unique and independent specialty throughout the world. Pediatric emergency medicine, however, is a relatively new subspecialty in the United States and a newer subspecialty in the rest of the world. In most of Europe and Asia, this specialty has yet to be developed. OBJECTIVE: To analyze the establishment of a new pediatric emergency care system in a developing country and identify areas of need and potential collaboration. SETTING: Pristina University Hospital, the main academic medical center in Kosovo, Federal Republic of Yugoslavia. METHODS: Data were collected using convenience sample surveys of all emergency visits in 2001, hospital admissions, health department statistics, and interviews with government officials and healthcare providers. RESULTS: Emergency care of children in Kosovo is provided by three parallel 24-hour clinic systems. During 2001, approximately 31,000 children sought emergency care (10,000 in the pediatric clinic, 5000 in an emergency facility, and 16,000 in the infectious disease clinic). There was no coordination or cooperation between these different facilities. No attempt was made to diagnose acute otitis media or urinary tract infection in young children. No records were kept. No physician in this study had pediatric emergency medicine and/or emergency medicine training. Prehospital providers had limited equipment and training. CONCLUSIONS: Hospital clinic systems in this environment provide high-volume and often a high level of acute care. Barriers to improved care include limited specialized training, lack of coordination between departments, and failure to establish a medical records system.

An implementation framework for household and community integrated management of childhood illness.

This paper describes the development and recent history of the third component of the Integrated Management of Childhood Illness (IMCI) strategy, improving household and community practices (HH/C IMCI). An implementation framework for this third component, developed through review of experiences of non-governmental organizations (NGOs) working in community-based child health and nutrition programmes, is then presented. This Framework responds to demand from NGOs and their partners for a description of the different categories of community-level activities necessary for the implementation of a comprehensive child health and nutrition programme. These categories of activities facilitate the systematic cataloguing, synthesis and coordination of organizational activities and experience. It also serves as a reference tool for improving communication of related community child health activities, and a guide for designing appropriate behaviour change strategies. The Framework was endorsed by participants in an international workshop held in Baltimore, Maryland in January 2001, and specified three linked elements that are integral to HH/C IMCI, supported by a multi-sectoral platform that addresses constraints communities face in adopting practices that promote health and nutrition. The three programmatic Elements critical to HH/C IMCI programmes are (1). improving partnerships between health facilities or services and the communities they serve; (2). increasing appropriate and accessible care and information from community-based providers; and (3). integrating promotion of key family practices critical for child health and nutrition. The Framework presented in this paper is an ideal tool for describing, sharing and coordinating efforts in the field, and is purposely descriptive rather than prescriptive.

Exclusions and limitations in children's behavioral health care coverage.

OBJECTIVE: The objective of this study was to identify benefit limits, diagnostic exclusions, and service exclusions of private behavioral health care plans that can influence the delivery of care to children. METHODS: A total of 128 commercial, employment-based behavioral health plans were examined for types of benefit limits, service exclusions, and diagnostic exclusions applicable to children. RESULTS: Almost half of the plans had restrictions on the number of outpatient visits, with limits ranging from 12 to 60 clinic visits a year. More than half of the plans had limitations on the number of inpatient days, ranging from 20 to 60 days a year. Diagnoses excluded from coverage included autism, mental retardation, problems related to child abuse, and impulse control disorders, such as kleptomania and pyromania. Half of the services excluded could be categorized as either social and human services or complementary medicine rather than as mental health care. CONCLUSIONS: Plans commonly had service and diagnostic exclusions that could disrupt children's health care. The results of the study emphasize a need to address the types of treatment covered by mental health insurance.

China: lowering maternal mortality in Miyun County, Beijing.

In Miyun County in China the medical authorities registered an elevated maternal mortality ratio which needed to be verified in order to design corrective changes. A decision was taken in 1988 to start a project of pilot interventions in the organization of maternal health services and access for obstetric emergencies. A control and pilot area were chosen in order to test the validity of the interventions. The reduction in maternal mortality from the main complications (postpartum haemorrhage and eclampsia) was impressive and no more maternal deaths were registered in the pilot area with reference to these causes. The overall maternal mortality ratio per 100,000 live births dropped by more than 75% in the pilot area throughout the three-year implementation period. It was therefore shown that the synergistic effect of additional training of medical workers and traditional birth attendants, improved health education, the provision of easier access to emergency care services, the establishment of obstetric rescue teams at the county level, generally improved MCH services, and strengthened management capacity for high risk pregnancies were the most appropriate interventions to lower maternal mortality.

PIP: This account provides a description for Miyun County (outside Beijing), China, of the number of maternal deaths, access to maternal health services, and system improvements during 1985-88. Maternal health care in Miyun County is provided through local township hospitals, county hospitals, and maternity hospitals. Community education is provided locally by village doctors and birth attendants at health stations. Health procedures were changed to include the application of Ministry of Public Health rules on strengthening referrals between village health stations, township hospitals, and county hospitals. Case management procedures were established for caring for postpartum hemorrhage, severe pregnancy-induced hypertension, amniotic embolism, shock, and neonatal asphyxia. Maternal health records were standardized, monitoring procedures for perinatal care were widely promoted, and high-risk pregnancies were identified and referred according to specific procedures. Six pilot areas were identified for testing the success of program implementation. Findings of this evaluation were that 27.3% (33) of maternal deaths were not reported. Maternal mortality was adjusted to account for these deficiencies (114/100,000). 60% of deaths were obstetrically-related. The leading causes were hemorrhage, followed by postpartum infections and pregnancy-induced hypertension. 63% of deaths involved insufficient prenatal care. Almost 40% of deaths were unnecessary, and about 66% were preventable. In the pilot townships hospitals showed improvements in hospital equipment and staff training. Only in the pilot areas did mortality rates improve. The maternal mortality rate in pilot areas declined by over 75%.

Trends in publicly financed prenatal and related services, 1975-1984.

We studied trends in Title V and health department financed prenatal and related services in U.S. countries from 1975-1984, years during which Medicaid and health insurance coverage for poor women were eroding. Information on prenatal services was obtained from background reports and telephone interviews with staff of State Maternal and Child Health programs. The number of counties providing prenatal care, particularly comprehensive care, rose considerably from 1975 to 1984; the largest rise occurred between 1982 and 1984. Federal initiatives accounted for about 25 percent of the increase in comprehensive care, while state-funded initiatives were responsible for the modest rise in counties offering routine care. The number of counties providing related components of care such as risk assessment and referral, obstetric or pediatric linkage with prenatal care, and outreach also rose markedly during the study years. Despite these secular trends, forty percent of U.S. counties did not offer prenatal care in health department operated or funded sites in 1984.

Diversity in provision and utilization of maternal and child health care in an urban area of Brazil.

Health services in Brazil are characterized by a multiplicity of providers. While many are ultimately funded from public sources, notably the National Social Security Scheme, a large proportion are provided by the private sector. This variety of providers of health care has hindered the development of comprehensive care and the coverage of those in greatest need. In recent years increasing attention has been given to ways of reducing the undesirable aspects of this situation. The Federal and State Governments have established committees to improve coordination between services and set up several pilot programmes. One concerned with improving the effective coverage of maternal and child services has been established in Sorocaba. Sorocaba is a medium-sized city which is typical of the many urban centres in the state of São Paulo. This paper describes a study which has provided information from a representative sample of women, who had recently had a baby, on their eligibility for care from the various health services available in the city and on their actual use of those services. This information has been used in the implementation of a pilot programme. Most mothers attended some service for antenatal care. Almost 20% used several services because their entitlement varied from scheme to scheme and some services provided only specific components of care. This applied also to preventive and curative infant care.

PIP: A survey of 296 mothers, with children born in March 1979, was conducted in Sorocaba, Sao Paulo State, Brazil, to describe the use and payment of health care, for baseline data for a maternal-child health program. Sorocaba, 96 km northwest of Sao Paulo, has 260,000 people and an infant mortality of 70/1000. Health care is dominated by private physicians and hospitals, and is largely reimbursed by public sources through the INAMPS social security payroll taxes, federal, state and municipal funds. There are also organized physician co-ops, and prepaid health plans. Because of diversity funding and services, there is an emphasis on curative medicine, duplication, and inequity of care. Extensive information is included in tables on socioeconomic, education, medical, insurance coverage, type of care received and residence characteristics of the subjects, expressed as percentages. Most (83%) mothers belonged to the Federal Social Security plan, and a third also belonged to a private insurance plan, usually through the husband's employment. Only 4% were not covered, except State and Municipal providers. Only 1.7% had no prenatal care. Any drugs needed were paid in part, although 17% had to go to more than one provider to get them. 98% were delivered in hospitals, 30% by Cesarean section, for which doctors receive higher fees. Many (62%) took their children for care by 2 months of age. Equal numbers used private or state health centers, while 14% used several sources. For infants' curative services 56% used private physicians or hospitals, 17% paid for care and 86% paid for drugs. Women in lower socioeconomic groups or with less education began prenatal care later and made significantly fewer visits for prenatal or infant care (p.001). The study has prompted discussions on coordination of outpatient services and identification of high risk patients.