Characterizing state strategies to assure primary care for mothers and children.

To assure primary care for all mothers and children, state health officials concerned with maternal and child health must be able to identify and characterize strategies to meet that goal. Since each state's Maternal and Child Health (MCH) Services Block Grant application reflects plans for reaching primary care goals and objectives, we reviewed the 1992 MCH Services Block Grant applications from the eight states in the Southeast (Department of Health and Human Services Region 4) to identify state strategies to improve primary care. We identified two major sets of strategies. The first set was directed toward increasing the number of providers and facilities and accounted for 14% of state strategies. The second set was directed toward improving the quality of care and constituted 86% of state strategies. Of these strategies to improve the quality of care, efforts to enhance the content of care, expand outreach, improve coordination, and improve intake and referral accounted for 46%, 32%, 15%, and 7%, respectively. The review of strategies delineated in state MCH Services Block Grant applications may provide an efficient mechanism to monitor the development of primary care at the state level.

Validity of the Maternal and Child Health Services Block Grant as an indicator of state infant mortality reduction initiatives.

Since state Maternal and Child Health Services Block Grant applications represent the most comprehensive source of information about community and state needs assessment, policy development, and program assurance for the population of mothers and children, these documents have the potential to play a central role in state accountability to Congress and the Maternal and Child Health Bureau. To measure the validity of block grant applications as a reporting mechanism, we assessed the sensitivity of the applications from seven states to strategies for reducing infant mortality. We used the independent coding of infant mortality strategies from the Healthy Futures/Healthy Generations Program intensive evaluation as the standard. Overall, the sensitivity of the block grant applications was only 45%. Since the open-ended design of the block grant applications does not appear to reflect the extent of state activity in infant mortality reduction, a uniform application should be adopted that will facilitate clear and systematic reporting of state activities.

The relationship between needs assessments and state strategies for meeting healthy people 2000 objectives: lessons from the Maternal and Child Health Services Block Grant.

Recognizing the critical role of needs assessments in the development of public health policy, the Omnibus Budget Reconciliation Act of 1989 required states to include needs assessments in their Maternal and Child Health Services Block Grant applications and to demonstrate a link between needs and programs. We examined this link by analyzing the relationship between strategies to meet health objectives and needs assessments in the applications for fiscal year 1992 for the eight states in the southeast (DHHS Region 4). Overall, the proportion of strategies based on reported needs was 88%. Numerous other needs, however, were not related to any strategies. Furthermore, there were neither needs nor strategies described for many objectives. These data required extensive analysis of the applications. A uniform structured report would facilitate the explicit collection of this information and thus the usefulness of this important document for policy development and accountability.

Back transfer: capability of community hospitals to serve chronically ill and convalescing infants.

Severe crowding in neonatal intensive care facilities may prevent many critically ill newborn infants from receiving optimal care. Crowding could be alleviated by back transferring chronically ill or convalescing infants to intermediate-level community hospitals where community-based care can be delivered. The purpose of this study was to assess the ability of such hospitals in North Carolina to care for these children. A telephone survey was administered to all 35 intermediate-level community hospitals that had > or = 600 births per year. Hospital resources were assessed on the first call, and a 1-day census was taken for three successive months. Total daily nursery census was 288. Back-transferred infants (32) and infants whose stay exceeded 5 days (32) constituted 24% of the nursery population. Each hospital had a pediatric medical director and necessary equipment to care for back transfers, and 80% of the hospitals could accept a back-transferred infant who was in a neonatal incubator, tube fed, receiving oxygen, 1400 gm, with mild and infrequent apnea and bradycardia--a common clinical picture in such infants. The most severe limitation to accepting infants for back transfer was the shortage of nursing staff appropriately trained to care for this population. These data have implications for effective discharge planning and the development of appropriate community-based, service-delivery systems.

Impact of an online analytic skills course.

This article describes the effect of an online analytic skills training course on professional development and practice and discusses recommendations for using this training modality in the public health workforce. The Enhancing Data Utilization Skills Through Information Technology initiative trained professionals in maternal and child health from 13 Southerntier state and local health departments to collect, analyze, and interpret data via a year-long Web-based course. The evaluation of this initiative was based on a model of change for health professionals that holds that training influences behavior by increasing knowledge, influencing beliefs related to the behavior, enhancing self-efficacy, and improving skills. Participants' knowledge, beliefs, and self-efficacy all increased significantly during the course. Participants' self-assessed skill levels increased significantly for each of 12 selected skills and overall for all skills combined. Distance learning is potentially an effective means for professionals to advance their skills while continuing to fulfill their work-related responsibilities.

Very-low-birthweight infants at seven years: an assessment of the health and neurodevelopmental risk conveyed by chronic lung disease.

To determine whether history of chronic lung disease (CLD) in children born at very low birthweight (VLBW) confers additional risk for impaired health, growth, and neurodevelopment, 17 VLBW children born in 1984 who had CLD (requiring supplemental oxygen more than 30 days after birth) in infancy and 28 VLBW children who did not have CLD were assessed at age 7 years. Assessments included a medical history, standard physical and neurological examinations, pulmonary-function tests, and tests of neuropsychological and psychoeducational functioning. Health status did not differ between the groups. In contrast, children with CLD did not perform as well in neuropsychological and psychoeducational assessments. Although CLD confers little added risk to health, it seems to add significantly to risks for poor school performance that are known to be associated with very low birthweight.

Relationship between the Maternal Social Support Index and the Parenting Stress Index in mothers of very-low-birthweight children now age 7.

Two measures, the Maternal Social Support Index and the Parenting Stress Index were used to assess parents' stress and social support among mothers of 7-yr-old children born at very low birthweight. The MSSI Total scores did not significantly correlate with the PSI Total Child, Total Parent, or Total Stress Indices, although they were significant, but modestly correlated with scores on the Parent subscale of Social Isolation. The relationship between parental stress and maternal social support requires continued investigation.

Enhancing technology skills of maternal and child health professionals.

OBJECTIVE: Information technology skills are essential for effective and efficient practice in maternal and child health (MCH). METHODS: Prior to the beginning of a web-based analytic skills training course, enrolled MCH professionals confidence in using e-mail and other Internet skills and beliefs about their usefulness were assessed. RESULTS: The assessment showed that participants believed strongly in the value of the specific technology skills but confidence in the ability to use these skills was low. CONCLUSION: An online technology skills training module was developed based on skills needed for the course to ensure that course participants learned and practiced the technology skills necessary to successfully complete the online analytic skills course. We describe the development, implementation, and results of the online technology skills module.

Identifying infants at risk: North Carolina's High-Priority Infant Program.

Recent federal legislation (e.g., PL 99-457, Part H, and amendments to the MHC block grant and Medicaid legislation) has focused attention on infants at risk for health and developmental problems. The ability to plan services for these infants would be strengthened by data that could be used for program accountability and evaluation. Using nurses based in local health departments, North Carolina's High-Priority Infant program currently identifies and follows infants with biologic (e.g., very low birth weight), environmental (e.g., psychosocial problems), and established (e.g., Down syndrome) risk conditions. Data from this program were collected to analyze specific features of its implementation, a necessary precursor to evaluating outcome.

Maternal stresses and depressive symptoms: correlates of behavior problems in young children.

In a sample of 115 mothers of 5- and 6-year-old children maternal everyday stressors, stressful life events, and maternal depressive symptoms were compared with mothers' reports of children's behavior problems. Maternal depressive symptoms did not mediate the relationship between either form of stress and child behavior problems. Maternal everyday stressors were more strongly associated with child behavior problems than were life events. Children of mothers indicating a high level of everyday stressors were 13 times more likely to be rated as having behavior problems than children of mothers reporting a low level of everyday stressors. The best prediction of mothers' reports of children's behavioral problems was provided by maternal everyday stressors and stressful life events considered simultaneously.

Statewide coverage of very low birth-weight infants and young teenage mothers in North Carolina's Child Service Coordination Program.

North Carolina's statewide, interagency Child Service Coordination Program (CSCP) serves children under five years of age with or at-risk for diverse health and developmental conditions. Preliminary assessment of the CSCP linked existing datasets to examine program coverage for two target populations: mothers < 15 year of age and infants < 1,500 g. The expectation that statewide program coverage would be higher for both risk groups in 1993 than in 1991 was true for mothers less than 15 years of age but not for infants < 1,500 g. This efficient method of evaluation can direct program outreach to the areas where it is most needed and provide a focus for more detailed program evaluation.

Ensuring public health professionals go the distance: a case study from an online data skills course.

Distance learning methodologies provide an effective and economical means for professional staff to advance their skills while continuing to meet their extensive work-related responsibilities. However, motivating professionals to engage in training opportunities that do not include the customary features of a trip out of town and time away from the office is a challenge for distance training initiatives aimed at the public health workforce. This article describes the implementation of several features designed to motivate public health professionals to participate in an online analytic skills course.

Building administrative support for your research: a neglected key for turning a research plan into a funded project.

There is more to grantsmanship than writing a good proposal. Planning, building, and negotiating administrative support may make the difference in a successful research effort.

Opportunities for older children and adolescents with disabilities through the Supplemental Security Income Program.

The revitalization of the Supplemental Security Income Program for low-income children with disabilities has important implications for state Title V programs for children with special health care needs. Historically, this program has focused primarily on recipients under the age of 7. The files of children between the ages of 7 and 16 referred to Children's Special Health Services, North Carolina's Title V children with special health care needs program from July to August 1991 were analyzed to determine whether there was documentation that children in this age group were receiving recommended services. Reports in the files indicated that most (n = 214, 77%) of the children's needs for specific services were being met. The utility of information that currently exists on older children and adolescents eligible for SSI for assisting Title V children with special health care needs programs in coordinating care is discussed.

Southeastern Title V program staff perceptions of state-level maternal and child health assessment skills.

OBJECTIVES: Since the publication of the Future of Public Health, a high priority has been placed on the development of the assessment capacity in public health programs. METHOD: Key informant interviews were conducted by telephone with selected program personnel of state Maternal and Child Health and Children with Special Health Care Needs programs in ten southeastern states to determine perceived deficiencies in skills needed to carry out assessments. RESULTS: We found that professional staff perceived that several fundamental assessment skills were available in their units, including collecting secondary data, and creating interagency groups and frameworks for assessment. In contrast, program staff perceived that their units did not have adequate skills to carry out many other critical assessment tasks, including the ability to analyze data using descriptive statistics. CONCLUSIONS: Our findings support the argument that more funds and staff resources must be devoted to the development of analytic skills, and to ensuring that consistent application of these skills is reinforced.

Sharing information and experiences about maternal and child health data sets through the World Wide Web.

Maternal and child health programs face increasing requirements to collect, analyze, and disseminate information on current health status and needs of population groups. Data sets vary according to data elements. Population groups, organizational and agency boundaries, and other situation-specific characteristics. Until recently, the major venue for sharing information about various dimensions of data sets has been informal, often word-of-mouth, communications. The World Wide Web provides an opportunity to replace these slow and incomplete information exchanges with instant and comprehensive ones. This article outlines the development of a web site that includes descriptive information about 12 MCH data sets.

Interaction between high-risk infants and their mothers: the NCAST as an assessment tool.

Using the NCAST Feeding, Teaching, and HOME Scales, we tested 37 high-risk infants matched with 37 healthy infants on gender, race, and socioeconomic status. All infants were 8 months old. A one-to-one matched case-control design was used to determine whether increased risk of impaired mother-infant interaction was associated with case status. Conditional logistic regression was used to control for possible confounding and to evaluate interaction. Of the 37 high-risk infant-mother dyads, 25 had a low score on one or more scales while only 10 of the control dyads had a low score on one or more of the three scales. The Feeding scale was the only assessment in which the association found in the univariate analysis persisted after adjusting for other variables. Because of its low cost and high efficiency, the NCAST battery appears to be valuable for directing more specialized intervention services in a high-risk infant population.

Can health professionals learn qualitative evaluation methods on the World Wide Web? A case example.

The Enhancing Data Utilization Skills through Information Technology (EDUSIT) project trained Maternal and Child Health professionals to collect, analyze and interpret data via a year-long web-based course. The overall goal of the project was to strengthen the technology and analytic skills of the public health workforce. This article describes and analyzes a web-based module for training public health professionals to use qualitative research and evaluation methods that was one of six offered within the EDUSIT project. The qualitative module consisted of six units: overview of qualitative methods, planning qualitative studies, conducting field observations, qualitative interviewing, analyzing qualitative data and presenting qualitative findings. Evaluation results found no statistically significant changes in specific knowledge or beliefs about qualitative methods. However, the change in participants' self-efficacy was statistically significant. Participants' self-reports also showed significant changes in perceived skill levels in 'collecting qualitative data through an interview' and 'analyzing and interpreting qualitative data'. Most participants rated each lesson within the qualitative methods module as valuable, and most found the teaching methods used satisfactory, emphasizing the value of both the didactic teaching and the practical exercises and team project. The most common difficulty reported was finding the time to complete the module requirements while also working full-time. Implications of these findings for web-based teaching of public health professionals are discussed.

Model indicators for maternal and child health: an overview of process, product, and applications.

OBJECTIVES: Further improvements in the health of mothers and children depend, in part, on collecting, analyzing, and interpreting relevant data correctly. Despite consistent efforts to improve data capacity and use during the past two decades, the need persists for a model set of maternal and child health (MCH) indicators to guide decisions about health conditions to be monitored, elements to be included in data sets, and definitions of measures. This article describes development, key characteristics, and major applications of a set of MCH Model Indicators (MCH MI) created to address these needs. METHODS: A conceptual model with five domains was created to organize and guide development of the indicators. The development process included systematic specification of concepts, formulas, age/gender groups, and data sources, as well as recommendations for frequency of surveillance. Information sources included published reports and expert opinion. RESULTS: There are 217 indicators distributed across domains as follows: 75 health status, 9 contextual characteristics, 16 health systems capacity and adequacy, 49 risk/protective status, and 68 health and related services. Twenty of the indicators, all of them in the health status domain, are recommended for routine surveillance. CONCLUSIONS: The indicators can be used to identify and address MCH problems, to complement and expand other sets of MCH indicators, to serve as standards for consistent definitions, to provide guidance for creation and revision of MCH and related data bases, and to provide a foundation for the development of related sets of indicators. Some of the indicators require further development, but the total MCH MI package constitutes a solid foundation for subsequent work, as well as for ongoing modifications that are essential if the Model Indicators are to remain responsive to MCH needs.

Public health nursing interventions to improve the use of a health service: using a pilot study to guide research.

This article demonstrates how a pilot study can provide useful direction for a research project. In planning a study to improve the use of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for Medicaid-eligible children, we tested our research methods and interventions (mailed pamphlets, telephone calls, home visits) on a small scale (N = 100) prior to implementing a large-scale (N greater than 2000) project. The issues and obstacles included obtaining cooperation from many agencies involved in administering the Medicaid program, addressing informed consent, assessing feasibility of methods for random sampling and random assignment, identifying sources of Medicaid data, designing and assessing validity and reliability of research tools, and testing the feasibility of implementing interventions in the field. Our experience may be particularly helpful for public health nurses who plan to investigate approaches to improve the use of services in federally mandated health programs where cooperation from federal, state, and local agencies is required.