Preventing low birth weight: is prenatal care the answer?

OBJECTIVES: To review the evidence of effectiveness of prenatal care for preventing low birth weight (LBW). METHODS: We reviewed original research, systematic reviews, meta-analyses and commentaries for evidence of effectiveness of the three core components of prenatal care--risk assessment, health promotion and medical and psychosocial interventions--for preventing the two constituents of LBW: preterm birth and intrauterine growth restriction (IUGR). RESULTS: Clinical risk assessment will fail to identify the majority of pregnancies at risk for preterm delivery or IUGR. While biophysical and biochemical modalities appear promising, their cost-effectiveness has not been demonstrated, nor can their routine use be recommended in the absence of effective interventions. Smoking cessation programs appear to be modestly effective. There is insufficient evidence to conclude a benefit for nutrition interventions, work counseling or preterm birth education. Only antenatal corticosteroid therapy has demonstrated a clear benefit in the tertiary prevention of preterm delivery. Interventions for which there is insufficient evidence to conclude a benefit include bed rest, hydration, sedation, cerclage, progesterone supplementation, antibiotic treatment, tocolysis without concomitant use of corticosteroids, thyrotropin-releasing hormone, psychosocial support and home visitation. Additionally, there is a paucity of evidence supporting the effectiveness of prenatal interventions, such as low-dose aspirin, bed rest, maternal hyperoxygenation, plasma volume expansion and antenatal fetal assessment, in preventing IUGR or its associated morbidity and mortality. CONCLUSIONS: Neither preterm birth nor IUGR can be effectively prevented by prenatal care in its present form. Preventing LBW will require reconceptualization of prenatal care as part of a longitudinally and contextually integrated strategy to promote optimal development of women's reproductive health not only during pregnancy, but over the life course.

Primary care services promoting optimal child development from birth to age 3 years: review of the literature.

OBJECTIVE: To examine the evidence base for primary health care services promoting the optimal development of typically developing children aged birth to 3 years. DATA SOURCES: Peer-reviewed publications addressing clinical evaluations of primary care services from the MEDLINE and PsychINFO databases. STUDY SELECTION: Criteria for selection were as follows: (1) publication between 1979 and 1999; (2) evaluation of efficacy or effectiveness of education, intervention, and care coordination services or validation of assessment approaches; (3) services applicable to an office practice setting; (4) target population including children aged birth to 3 years; and (5) publication in English. DATA EXTRACTION: A total of 312 publications were abstracted and reviewed by both of us; 47 were selected for inclusion. DATA SYNTHESIS: Assessments of parental concerns and psychosocial risk factors using validated approaches seem to be more accurate in identifying developmental problems than clinicians' appraisals. In general, study results support the efficacy of (1) primary care educational efforts toward promoting optimal parent-child interaction, parents' understanding of child temperament, book-sharing activities, and approaches to healthy sleep habits and (2) office interventions such as counseling for the management of excessive infant crying and sleep problems. CONCLUSIONS: The literature suggests that many primary care activities promoting the optimal development of children are efficacious. Evaluations of developmental assessment and services in primary care should be expanded in depth and breadth. The implications for clinical practice, training, and health care policy are discussed.

Provider encouragement of breast-feeding: evidence from a national survey.

OBJECTIVE: To examine the influence of provider encouragement on breast-feeding among women of different social and ethnic backgrounds in the United States. METHODS: A nationally representative sample of 2017 parents with children younger than 3 years was surveyed by telephone. The responses of the 1229 women interviewed were included in the analysis. Respondents were asked to recall whether their physicians or nurses had encouraged or discouraged them from breast-feeding. The effects of provider encouragement on breast-feeding initiation and duration were evaluated by multivariate logistic regression. The sample was then stratified to allow subset analyses by race and ethnicity, education, income class, age group, and marital status. RESULTS: More than one-third (34.4%) of respondents did not initiate breast-feeding. Three-fourths (73.2%) of women reported having been encouraged by their physicians or nurses to breast-feed; 74.6% of women who were encouraged initiated breast-feeding, compared with only 43.2% of those who were not encouraged (P < 0.001). Women who were encouraged to breast-feed were more than four times (relative risk 4.39; 95% confidence interval 2.96, 6.49) as likely to initiate breast-feeding as women who did not receive encouragement. The influence of provider encouragement was significant across all strata of the sample. In populations traditionally less likely to breast-feed, provider encouragement significantly increased breast-feeding initiation, by more than threefold among low-income, young, and less-educated women; by nearly fivefold among black women; and by nearly 11-fold among single women. CONCLUSION: Provider encouragement significantly increases breast-feeding initiation among American women of all social and ethnic backgrounds.

The health development organization: an organizational approach to achieving child health development.

The health development organization (HDO) is a new approach to the organization and delivery of children's health and social services. The HDO would combine the best features of vertically integrated HMOs with horizontally integrated, child-focused social services and longitudinally integrated health promotion strategies. Its mandate would be to develop the health of children in a community. The impetus for creating HDOs is a growing body of evidence in chronic disease epidemiology, developmental psychopathology, early intervention research, and life course cohort studies that point to childhood as the period of life during which adult health status is determined and the opportunities for health capital formation are highest. Thus, a new kind of health care organization or framework, like the HDO, is needed to integrate a full range of critical services for promoting children's development.

Family planning clinic patients: their usual health care providers, insurance status, and implications for managed care.

PURPOSE: To understand the extent to which family planning clinic patients have health insurance or access to other health care providers, as well as their preferences for clinic versus private reproductive medical care. METHOD: An anonymous self-report questionnaire was administered at three Planned Parenthood clinics in Los Angeles County to 780 female patients aged 12-49 years. Dependent variables included insurance status, usual source of care, and a battery of questions regarding the importance of confidentiality. RESULTS: A total of 356 adolescents (aged 12-19 years) and 424 adults (aged 20-49 years) completed the survey in 1994. Fifty-nine percent of adolescents and 53% of adults had a usual source of care other than the clinic. The majority of each group reported some degree of continuity of care in their usual provider setting. Nearly half (49%) of all adolescents had health insurance compared with 27% of adults. Adolescents cited not wanting to involve family members as the primary reason for not using their usual providers, whereas adults were more likely to cite being uninsured. The majority of both adult and adolescent patients indicate they would prefer the clinic over private health care if guaranteed health care that was free, confidential, or both. CONCLUSION: Despite many patients' having health insurance and other sources of health care, family planning clinics were primarily chosen because of cost and confidentiality. Their reasons for preferring clinics may continue despite changes in access to insurance or efforts to incorporate similar reproductive services into mainstream health care provider systems. Making public or private health care funds available to family planning clinics through contracts or other mechanisms may facilitate patients' access to essential services and reduce potential service duplication.

Access to health care for children with special health care needs.

OBJECTIVE: To assess the role health insurance plays in influencing access to care and use of services by children with special health care needs. METHODS: We analyzed data on 57 553 children younger than 18 years old included in the 1994-1995 National Health Interview Survey on Disability. The survey obtained information on special health care needs, insurance status, and access to and use of health services. Bivariate and multivariate analyses were used to assess the association of insurance with several measures of access and utilization, including usual source of care, site of usual care, missed or delayed care, and use of ambulatory physician services. RESULTS: Using the federal Maternal and Child Health Bureau definition of children with special health care needs, we estimate that 18% of US children under 18 years old had an existing special health care need in 1994-1995. An estimated 89% of these children had some form of health insurance coverage, most often private health insurance. Insured children were more likely than uninsured children to have a usual source of care (96.9% vs 79.2%). Among those with a usual source of care, insured children were more likely than uninsured children to have an identified regular clinician (87. 6% vs 80.7%). Insured children were less likely to report unmet health needs, including medical care (2.2% vs 10.5%), dental care (6. 1% vs 23.9%), prescriptions, and/or eyeglasses (3.1% vs 12.3%), and mental health care (.9% vs 3.4%). Insured children were also more likely to have a physician contact in the past year (89.3% vs 73.6%) and have more physician contacts on an annual basis (8.5 vs 4.1 contacts). Unexpectedly, no differences were found between insured and uninsured children in availability of after hours medical care (evenings and weekends) or satisfaction with care. We also found some modest differences in access between publicly and privately insured children. Privately insured children were more likely to have a usual source of care (97.6% vs 95.3%) and a regular clinician (91.0% vs 81.1%). Privately insured children were also less likely to report dissatisfaction with care at their usual site of care (14. 9% vs 21.0%) and have access to care on evenings and weekends (6.8% vs 13.4%). No substantial differences were found between privately and publicly insured children in prevalence of unmet health needs or delays in obtaining care due to cost. CONCLUSIONS: This study illustrates the importance of health insurance for children with special health care needs. Continued efforts are needed to ensure that all children with special health care needs have insurance and that remaining access and utilization barriers for currently insured children with special health care needs are also addressed.

Prevalence, impact, and trends in childhood disability due to asthma.

BACKGROUND: Although not widely recognized as such, asthma is the single most prevalent cause of childhood disability and has contributed to a substantial rise in the overall prevalence of disability among children during the past 25 years. OBJECTIVE: To provide a national profile of the prevalence, impact, and trends in childhood disability due to asthma. (Disability is a long-term reduction in the ability to participate in children's usual activities, such as attending school or engaging in play, due to a chronic condition.) METHODS: We derived our primary findings from a cross-sectional, descriptive analysis of 62171 children younger than 18 years who were included in the 1994-1995 National Health Interview Survey. MAIN OUTCOME MEASURES: Outcome measures include the presence of disability, degree of disability, restricted activity days, school absence days, and use of hospital and physician services. We also used data from the 1969-1970, 1979-1981, and 1994-1995 National Health Interview Surveys to assess trends in the prevalence of disability due to asthma. RESULTS: A small, but significant, proportion of children, estimated at 1.4% of all US children, experienced some degree of disability due to asthma in 1994-1995. Prevalence of disability due to asthma was higher for adolescents (odds ratio [OR], 1.64), black children (OR, 1.66), males (OR, 1.23), and children from low income (OR, 1.46) and single-parent families (OR, 1.37). Disabling asthma resulted in an annual average of 20 restricted activity days, including 10 days lost from school-almost twice the level of illness burden as experienced by children with disabilities due to other types of chronic conditions. Finally, prevalence of disabling asthma, as reported in the National Health Interview Survey, has increased 232% since 1969, the first year that electronic data are available from the survey. In contrast, prevalence of disability due to all other childhood chronic conditions increased by 113% over the same period. CONCLUSIONS: Disabling asthma has profound effects on children. The social costs of asthma are likely to rise in the future if current trends in the prevalence of disabling asthma continue.

Firearm storage patterns in US homes with children.

OBJECTIVES: This study determined the prevalence and storage patterns of firearms in US homes with children. METHODS: We analyzed data from the 1994 National Health Interview Survey and Year 2000 objectives supplement. A multistage sample design was used to represent the civilian noninstitutionalized US population. RESULTS: Respondents from 35% of the homes with children younger than 18 years (representing more than 22 million children in more than 11 million homes) reported having at least 1 firearm. Among homes with children and firearms, 43% had at least 1 unlocked firearm (i.e., not in a locked place and not locked with a trigger lock or other locking mechanism). Overall, 9% kept firearms unlocked and loaded, and 4% kept them unlocked, unloaded, and stored with ammunition; thus, a total of 13% of the homes with children and firearms--1.4 million homes with 2.6 million children--stored firearms in a manner most accessible to children. In contrast, 39% of these families kept firearms locked, unloaded, and separate from ammunition. CONCLUSIONS: Many children live in homes with firearms that are stored in an accessible manner. Efforts to prevent children's access to firearms are needed.

Community health report cards. Results of a national survey.

INTRODUCTION: The purpose of this research is to examine the state-of-the-art in community health report card development and use in order to increase their effective integration into community health improvement efforts. METHODS: A mailed survey was sent to 115 "report card" communities nationwide. This list was generated through multiple key informants at the national, regional, and state levels. Seventy-four percent (85/115) were eligible for the study. The report cards returned were inventoried for: quality of their data, comprehensiveness, presentation, appropriateness to target audiences, purpose and sponsorship, relevance to policy development, community involvement, comparability, replicability, and other factors. RESULTS: Of the 85 eligible projects, 65 responded. The report cards varied significantly in all areas. Only one half of communities used pre-existing formats or the experience of others to guide this resource-intensive development process. Data collection was the greatest challenge encountered in development. Local health departments, hospitals, and non-profit civic groups were the community groups most likely to be involved in development. CONCLUSION: There is need for infrastructure, technical assistance, and improved, easy-to-use tools to facilitate the report card development process and the sharing of expertise and experience among involved communities. Greater systematization of the process would enhance the reasonableness and sustainability of the effort. Broad community involvement, including support of the local health department, other community agencies, as well as the local business community, may be key to their success.

Enrollment in the State Child Health Insurance Program: a conceptual framework for evaluation and continuous quality improvement.

Children's enrollment in the State Child Health Insurance Program (SCHIP) is a key indicator of program impact. Past studies demonstrate that many children eligible for Medicaid or for private employer-based insurance remain uninsured, indicating that eligibility does not guarantee either enrollment or access to medical care. Important features of SCHIP evaluation include not only eligibility thresholds and enrollment volume, but also program retention, transitions in coverage, and access to medical care. Focusing on SCHIP features that affect children's participation and continuity of coverage would allow states to continually improve procedures that affect enrollment. An exploration of federal and state policy options suggests several approaches for creating evaluation strategies that can stimulate ongoing improvement.

Prevalence and impact of parent-reported disabling mental health conditions among U.S. children.

OBJECTIVE: To provide a current national profile of the prevalence and impact of parent-reported disabling mental health conditions in U.S. children. METHOD: A cross-sectional descriptive analysis of 99,513 children younger than 18 years old included in the 1992-1994 National Health Interview Survey (NHIS). The response rate exceeded 94% in each year. Disability is defined as the long-term reduction in a child's ability to perform social role activities, such as school or play, as a result of his/her mental health condition. RESULTS: On average, 2.1% of U.S. children were reported to suffer from a disabling mental health condition in 1992-1994. The most common reported causes of disability include mental retardation, attention-deficit hyperactivity disorder, and learning disabilities. While national prevalence estimates were produced for some low-prevalence conditions such as autism (38/100,000), for many specific diagnoses the reported prevalence rates were too low for accurate national population estimates using this data set. Logistic regression analysis demonstrates that prevalence of a disabling mental health condition was higher for older children; males; children from low-income, single-parent families; and those with less education. These conditions are also associated with high rates of special education participation (approximately 80%) and health system use. CONCLUSIONS: The NHIS provides a useful and untapped resource for estimating the prevalence of disabling mental health conditions. These conditions are increasingly prevalent and have a profound impact on children and the educational and health care systems.

Challenges in securing access to care for children.

Congressional approval of Title XXI of the Social Security Act, which created the State Children's Health Insurance Program (CHIP), is a significant public effort to expand health insurance to children. Experience with the Medicaid program suggests that eligibility does not guarantee children's enrollment or their access to needed services. This paper develops an analytic framework and presents potential indicators to evaluate CHIP's performance and its impact on access, defined broadly to include access to health insurance and access to health services. It also presents options for moving beyond minimal monitoring to an evaluation strategy that would help to improve program outcomes. The policy considerations associated with such a strategy are also discussed.

The role of Medicaid in ensuring children's access to care.

CONTEXT: Congress enacted a series of laws beginning in the mid 1980s to expand Medicaid eligibility for children, especially those in poor families. As a result, Medicaid enrollment of children has nearly doubled over the past decade. OBJECTIVE: To assess the effectiveness of Medicaid in improving access to and use of health services by poor children. DESIGN: Analysis of cross-sectional survey data from the 1995 National Health Interview Survey. Poor children with Medicaid were compared to poor children without insurance and nonpoor children with private insurance. SETTING AND PARTICIPANTS: A total of 29711 children younger than 18 years (3716 poor children with Medicaid, 1329 poor children without insurance, 14609 nonpoor children with private insurance, and 10057 children with other combinations of poverty and insurance status) included in a nationally representative stratified probability sample of the US noninstitutionalized population. MAIN OUTCOME MEASURES: Usual source of care, access to a regular clinician, unmet health needs, and use of physician services. RESULTS: Poor children with Medicaid compared to poor children without health insurance experienced superior access across all measured dimensions of health care, including presence of a usual source of care (95.6% vs 73.8%), frequency of unmet health needs (2.1 % vs 5.9%), and use of medical services (eg, > or =1 physician contact in past year) (83.9% vs 60.7%). Poor children with Medicaid compared to nonpoor children with private insurance used similar levels of physician services (83.9% vs 84%), but were more likely to have unmet health needs (2.1 % vs 0.6%) and were less likely to have a usual source of care (95.6% vs 97.4%). CONCLUSION: Medicaid is associated with improvements in access to care and use of services. However, there remains room for improvement when Medicaid is judged against private health insurance. The Balanced Budget Act of 1997 contains several Medicaid provisions that could stimulate further improvements in access for poor children.

Differences between child and parent reports of symptoms among Latino children with asthma.

OBJECTIVES: To determine, in a population of predominantly Latino children with asthma 6 to 18 years old, whether parent and child reports of asthma symptoms with exercise differ and to evaluate the validity of child and parent reports of symptoms. DESIGN: Data obtained from child and parent interviews; pulmonary function tests (forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow25-75, peak expiratory flow), and observation of symptoms after exercise. SETTING: Three summer camps for minority children with asthma in Los Angeles County. PARTICIPANTS: A total of 97 children with asthma (78% Latino, 12% non-Latino White, 9% Other; 6 to 18 years of age) and their parents. INTERVENTION(S): None. PRIMARY OUTCOME MEASURES: Child and parent reports of cough and wheezing with exercise and pulmonary function tests before and after exercise. While at camp, children underwent spirometry after completing the self-administered survey. The pulmonary function tests were conducted and interpreted according to the pediatric specifications for spirometry, and results >80% of predicted, adjusted for gender, age, height, and race, were considered normal. Six peak expiratory flow rates (PEFR) by peak flow meter also were recorded by trained research assistants immediately before spirometry, and values >80% of predicted based on height were considered normal. To observe child symptoms with exercise, children participated in a relay running race of 200 feet followed by a swimming race of 300 feet. Research assistants measured heart rate and 6 PEFRs using ASSESS portable peak flow meters immediately before and after each exercise. A positive exercise challenge was defined as a 15% reduction in mean PEFR and/or observed asthma symptoms (cough, wheezing, chest pain, asthma attack). RESULTS: Of the children, 18% reported never having a cough when they exercised, 46% reported having it occasionally when they exercised, and 36% reported having it quite often or always when they exercised. For wheezing, 20% of children reported never having wheezing when they exercised, 35% having it occasionally when they exercised, and 45% having it quite often or always when they exercised. Parents reported fewer symptoms than did their children. Of the parents, 34% reported that their children did not have cough with exercise, 37% reported few to some days, and 29% reported most days or every day. Forty-seven percent of parents reported that their child did not wheeze with exercise in the last 2 months, 35% reported wheezing on a few days to some days, and 17% reported wheezing most days to every day. Parent and child reports of cough or wheezing after exercise correlated mildly with each other (parent/child cough r = 0. 23; kappa = 0.03; parent/child wheezing r = 0.21; kappa = 0.14). Children were more likely to report cough: 59 of 71 (83%) of children versus 44 of 71 (62%) of parents. The 22 children who reported cough when their parents did not account for most of the disagreement between parents and children. Children were more likely than were their parents to report wheezing; 55 of 69 (80%) children versus 36 of 69 (52%) parents reported that the child wheezed. The 24 children who reported wheezing when their parents did not account for most of the disagreement between parents and children. Forty-seven percent of the children had a value <80% of predicted for at least one of the four spirometry tests; 29% of mean baseline PEFRs were <80% of predicted. Overall, 86% of the children met one or more of the following: any percent of predicted pulmonary function tests <80% or any symptom or PEFR reduction of 15% after exercise, or other occurrence of nonexercise symptoms during camp. Almost all child reports of cough and wheezing correlated significantly with the criterion validity criteria. For example, child reports of wheezing were, as expected, correlated negatively with the percent of predicted FEV1 (r = -0.28) and correlated positive

Improving the quality of healthcare for children: implementing the results of the AHSR research agenda conference.

OBJECTIVE: To describe the rationale, development, content, and results of the AHSR-sponsored conference on developing a research agenda focused on improving the quality of care for children. DATA SOURCES AND METHODS: Planning documents, background papers, and conference proceedings. PRINCIPAL FINDINGS: The conference developed the research agenda focused on (1) monitoring the health of children; (2) evaluating the efficacy and effectiveness of health services for children; (3) assessing the quality of healthcare provided to children; (4) improving the quality of healthcare within health systems; (5) assessing the performance of community systems for children; (6) exploring the impact of different financial incentives on the provision of pediatric healthcare; and (7) developing and disseminating clinical practice guidelines and other information to physicians, families, and consumers. Specific issues and research questions in each area are also presented. Strategies for implementing the research agenda are presented and include: (1) expanding the child health services research workforce; (2) developing child healthcare quality improvement research centers; (3) conducting research in specific high-priority areas; (4) focusing research on improving the health of vulnerable populations; (5) improving child health data and collection systems at the national level; (6) developing better community health monitoring for children; (7) building and supporting research networks and a consortium of research users; and (8) developing a coordinated interagency federal effort to advance this agenda and to provide accountability for its completion. CONCLUSION: The proposed research agenda should be a national priority so that all Americans can be assured that children are receiving the best quality of care that the United States can provide.

Overview of issues in improving quality of care for children.

OBJECTIVE: To provide a framework for a research agenda-setting conference on quality of care for children. DATA SOURCES/STUDY SETTING: Literature review. CONCLUSIONS: Research on quality of care for children has lagged behind its counterpart for adults. Defining key issues and questions in seven topic areas-the health of children; the efficacy and effectiveness of health services for children; assessing quality of care; improving quality of care within health services delivery systems; assessing and improving quality at the community level; getting financial incentives right; and disseminating information about the results of research investigations-will facilitate the development of an effective research strategy. Ultimately, enhanced information in these areas will lead to improvements in the processes and outcomes of care for children.

Assessing the performance of community systems for children.

OBJECTIVE: To present a framework for measuring the quality of community systems for children, based on key attributes of systems performance for children's services. We present a research agenda for refining the model, evaluating indicators across the performance domains identified, developing normative standards for performance, and assessing the empirical basis for performance criteria. PRINCIPAL FINDINGS: Systems performance can be measured. A systems approach to evaluating community systems for children needs to incorporate the multilevel service delivery networks, programs, and systems of care for children. A model of community systems performance for children includes key dimensions of structure, financing, and accountability. Attributes within these dimensions serve as indicators that communities can use to evaluate systems quality. Performance standards can be based on the evidence from field demonstrations as well as from normative assessments. RECOMMENDATIONS: The model of community systems performance should be refined and developed using empirical findings of analyses of children's systems. A set of indicators that capture vital aspects of performance and that are relevant, scientifically valid, and feasible should be developed and tested in field studies. Once indicators are evaluated for use in performance monitoring, communities will be able to implement performance monitoring.