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Objectives. We assessed whether there were associations between maternal mental health and individual and co-occurring parenting stressors related to social and financial factors and child health care access. Methods. We used cross-sectional data from the 2000 National Survey of Early Childhood Health. The 5-item Mental Health Inventory was used to measure self-reported mental health. Results. After we controlled for demographic covariates, we found that the following stressors increased the risk of poor maternal mental health: lack of emotional (odds ratio [OR]=3.4; 95% confidence interval [CI]=2.0, 5.9) or functional (OR = 2.2; 95% CI = 1.3, 3.7) social support for parenting, too much time spent with child (OR = 3.5; 95% CI = 2.0, 6.1), and difficulty paying for child care (OR = 2.3; 95% CI = 1.4, 3.9). In comparison with mothers without any parenting stressors, mothers reporting 1 stressor had 3 times the odds of poor mental health (OR = 3.1; 95% Cl = 2.1, 4.8), and mothers reporting 2 or more stressors had nearly 12 times the odds (OR = 11.7; 95% Cl = 7.1, 19.3). Conclusions. If parenting stressors such as those examined here are to be addressed, changes may be required in community support systems, and improvements in relevant social policies may be needed.

BACKGROUND. The increasing scope of health supervision recommendations challenges well-child care delivery in the United States. Comparison of the United States with other countries' delivery systems may highlight different assumptions as well as structural approaches for consideration. OBJECTIVE. Our goal was to describe the process of well-child care delivery in industrialized nations and compare it to the US model of child health care. METHODS. Literature reviews and international experts were used to identify 10 countries with unique features of well-child care delivery for comparison to the United States. Key-informant interviews using a structured protocol were held with child health experts in l0 countries to delineate the structural and practice features of their systems. Site visits produced additional key informant data from 5 countries (Netherlands, England, Australia, Sweden, and France). RESULTS. A primary care framework was adapted to analyze structural and practice features of well-child care in the 10 countries. Although well-child care content is similar, there are marked differences in the definitions of well-child care and the scope of practice of primary care professionals and pediatricians specifically who provide this care across the 10 countries. In contrast to the United States, none of the countries place all well-child care components under the responsibility of a single primary care provider. Well-child care services and care for acute, chronic, and behavioral/developmental problems are often provided by different clinicians and within different service systems. CONCLUSIONS. Despite some similarities, well-child care models from other countries differ from the United States in key structural features on the basis of broad financing differences as well as specific visions for effective well-child care services. Features of these models can inform child health policy makers and providers in rethinking how desired improvements in US well-child care delivery might be sought. Key Words developmental care, preventive services, preventive health care visits Abbreviations AAP--American Academy of Pediatrics MCH--maternal and child health PMI--Protection Maternelle et Infantile, WELL-CHILDCARE IS the cornerstone of US preventive pediatrics, combining elements of health supervision, anticipatory guidance, growth/development monitoring, and immunizations to promote children's health and development. (1) The goal of well-child [...]

Background. The list of recommended pediatric preventive services has grown considerably in the past decade, and clinician variability, clinician distribution, and other correlates of provision of these basic preventive services (BPS) are not known. Objective. To describe the proportion of high-quality basic pediatric preventive services, exclusive of immunizations, reported by parents and to identify sociodemographic and health system predictors and health service correlates of provision of these services. Study Design. The study used cross-sectional data on 2041 children, 4 to 35 months of age, in the 2000 National Survey of Early Childhood Health. Outcome Measures. The BPS measure assesses the receipt of (1) developmental assessment, (2) injury prevention counseling, (3) screening for parental smoking, (4) guidance on reading to the child, and (5) guidance on 14 other topics (assessed as a composite score). The BPS scale categorizes the receipt of services as excellent, good, fair, or poor. Results. Most children received excellent (34.9%) or good (31.5%) care, but many received fair (24.9%) or poor (8.7%) care. Sociodemographic and health care factors such as race/ethnicity, insurance, and practice setting were not associated with BPS levels. Higher BPS scores were associated with parental reports of longer well-child visits, more counseling regarding family and community risk factors, lower rates of delayed or missed care, and greater satisfaction. Conclusions. Two thirds of children receive good or excellent basic preventive care, as determined with this composite, and no disparities according to race/ethnicity, income, or health insurance status of families (which are often found to be associated with health care access) were found. This equitable distribution of high-quality care suggests a high level of clinician professionalism. Duration of visits may be a key factor to improve quality of care. Because of its association with other services, processes, and outcomes of care, the BPS scale may serve as a useful construct for monitoring quality and stimulating efforts to improve national pediatric preventive care. ABBREVIATIONS. NSECH, National Survey of Early Childhood Health; BPS, basic preventive services; PHDS, Promoting Healthy Development Survey; AAP, American Academy of Pediatrics., Pediatric primary care is designed to prevent disease, disabilities, and injuries and to promote children s health and well-being. (1) Recommendations for the periodicity and content of pediatric well-child visits [...]

Objective. To generate a national picture of performance in the area of preventive and developmental services for children aged 4 to 35 months using 4 composite quality measures in the areas of 1) anticipatory guidance and parental education, 2) screening for family psychosocial risks, 3) screening for smoking and drug and alcohol use in the home, and 4) provision of family-centered care. Methods. Data from the National Survey on Early Childhood Health (N = 2068) were used to calculate the 4 composite performance measures, which, taken together, represent 23 topics included in the American Academy of Pediatrics health supervision guidelines. The reliability and degree of redundancy within and across these 4 measures were evaluated. Four methods for scoring these measures were used. Quality scores for subgroups of children were calculated, and logistic regression analysis was performed to examine the association of demographic, health, and health system variables with receiving recommended care. Results. Regardless of the scoring method used, performance is highest in areas of family-centered care and screening for smoking and drug and alcohol use in the home. Performance is lowest in the areas of anticipatory guidance and education and assessment for family psychosocial risks. Using a scoring method that takes into account parent preferences for guidance and beliefs about discussing psychosocial topics, composite quality measure scores ranged from 13.5% to 59.6% of parents of young children receiving recommended care. Overall, 94.0% of parents reported I or more unmet needs for parenting guidance, education, and screening by pediatric clinician(s) in 1 or more of the content of care areas evaluated. Uninsured children and children aged 18 to 35 months are disproportionately represented among the 15.3% of children whose parents indicated an unmet need in each of the 4 areas of care. Although the reliability of each composite measure was high, no single item in any composite was highly correlated with the remaining combined items. Performance on any 1 composite measure for a child was only somewhat predictive of performance for the other measures. There are significant variations in performance on the basis of child age, race, insurance status, maternal education, marital status, and parent language as well as other factors. Conclusions. National results using 4 complementary composite quality measures confirm the need for improving the quality of preventive and developmental services for young children in the United States. The 4 measures identify areas of care and subgroups of children for whom improvements in quality are most needed. The measures provide a parsimonious yet comprehensive assessment across distinct health supervision topics and 4 essential aspects of preventive and developmental services. Until valid measures of outcomes of preventive and developmental services are identified or 1 single process of care measure is shown to be highly predictive of these outcomes, assessing multiple aspects of recommended care will be necessary to assess performance of health care providers or systems of care. Pediatrics 2004;113:1973-1983; quality of care, health supervision, quality measures., ABBREVIATIONS. AGPE, anticipatory guidance and education; FCC, family-centered care; FA, family psychosocial risks; SDA, smoking and drug and alcohol use; APP, American Academy of Pediatrics; PHDS, Promoting Healthy Development Survey; [...]

Objectives. The aims of this study are to 1) assess parent satisfaction with well-child care for their young child and 2) identify how global satisfaction ratings and parent reports on the processes of care vary with child and family characteristics, health care received, and health system factors. Methods. The National Survey of Early Childhood Health is a telephone survey that used a stratified random-digit-dial sampling design to achieve a nationally representative sample of 2068 children and 4 to 35 months. Parents provided global ratings of satisfaction with their child's well-child visits (range 0-100) and reported their satisfaction with information provided and the time spent with the provider. A subsample of parents whose child has a particular provider for well-child care (n = 930) also reported their likelihood of recommending their provider. Results. The mean global satisfaction rating is 86.9 (standard error: 6.1). Approximately 94% of parents of young children reported information satisfaction, 88% reported time satisfaction, and 79% would recommend their child's provider. Bivariate analysis shows lower satisfaction for uninsured children but few differences associated with insurance type or health care setting. In multivariate analyses including child and family factors and health system factors, Hispanic, Spanish-speaking mothers of young children have lower odds than non-Hispanic white mothers of reporting information (odds ratio [OR]: 0.32; 95% confidence interval [CI]: 0.13-0.79) and time satisfaction (OR: 0.44; 95% CI: 0.21-0.90). Parents of children who experienced missed or delayed care have lower odds of time satisfaction (OR: 0.27; 95% CI: 0.16-0.46) and have lower global satisfaction. Greater length of well-child visits is consistently associated with greater satisfaction on all 4 measures. Conclusion. Although most parents reported relatively high levels of satisfaction with well-child care, shorter length of well-child visits and experiencing missed or delayed care are the 2 factors consistently associated with lower satisfaction using each of the measures. Efforts to improve satisfaction ratings might focus on improving the delivery of well-child care and ensuring that parents get the time they need. Pediatrics 2004; 113:1965-1972; quality of care, child health, satisfaction., ABBREVIATIONS. CAHPS, Consumer Assessment of Health Plan Satisfaction; NSECH, National Survey of Early Childhood Health; MHI-5, 5-item Mental Health Index; CI, confidence interval; OR, odds ratio. Consumer reports of health [...]

Objective. To determine the proportion of children aged 10 to 35 months who were reported ever to have received a developmental assessment (DA) and to examine characteristics of the child, family, and health care setting associated with the receipt of a DA. Methods. The National Survey of Early Childhood Health, conducted in 2000, is a survey of 2068 parents of children 4 to 35 months of age. Children were classified as having received a DA in response to 2 questions: whether the child's pediatric provider ever told parents that he or she was doing a "developmental assessment" and/or parents recalled explicit components of a DA, such as stacking blocks or throwing a ball. Parent-reported receipt of a DA was assessed in relationship to child and family, health care access, other measures of health care content and process, and measures of quality and satisfaction. Results. Approximately 57% of children 10 to 35 months of age ever received a DA. Forty-two percent of parents recalled ever being told by their child's pediatric provider that a DA was being done. Thirty-nine percent recalled their child's being asked to perform specific tasks routinely included in a DA. Bivariate analysis indicates that receipt of a DA is not associated with child or family sociodemographic characteristics such as maternal education and household income, with the exception of race/ethnicity. Less acculturated Hispanic parents reported a DA more frequently than parents in other racial/ ethnic groups (66% vs 56%). A smaller proportion of parents whose children who used community health centers reported their child's ever having received a DA compared with children who use other settings (51% vs 60%). Compared with other children, parents whose child ever received a DA reported more frequently than other parents that the time spent with the child's provider during the last well-child visit was adequate (94% vs 80%). They also reported longer visits (19 minutes vs 16 minutes), higher family-centered care ratings (mean: 71 vs 59), and higher satisfaction with well-child care (8.9 vs 8.4). Receipt of a DA is also associated with the content of developmentally focused anticipatory guidance received. For each health supervision topic analyzed, frequency of discussion is higher for children who ever received a DA. In multivariate analysis, odds of receiving a DA are higher for children with longer visits with the provider (odds ratio: 1.03; 95% confidence interval: 1.01-1.05) and lower for children in community health clinics compared with a private office (odds ratio: 0.61; 95% confidence interval: 0.39-0.96), even accounting for total well-child visits to the pediatric provider. Conclusion. Although guidelines endorse the routine provision of DAs, parents of many children do not report receiving DAs. Children who receive assessments are more likely to receive other developmental services, and their parents are more likely to report greater satisfaction with care and rate the interpersonal quality of well-child care more favorably. The substantial number of children who do not receive these routinely recommended services raises important questions about the quality of care received. Pediatrics 2004;113:1926-1933; developmental assessment, anticipatory guidance, quality of care, children., ABBREVIATIONS. AAP, American Academy of Pediatrics; DA, developmental assessment; NSECH, National Survey of Early Childhood Health; PEDS, Parents' Evaluation of Developmental Status; FCC, family centered care; OR, odds ratio; CI, [...]

Background. Insurance status has been shown to have an impact on children's use of preventive and acute health services. The objective of this study was to determine the relationship between insurance status and vaccination coverage among US preschool children aged 19 to 35 months. Methods. We linked data from 2 national telephone surveys, the National Immunization Survey and the National Survey of Early Childhood Health, conducted during the first half of 2000. Children were considered up to date (UTD) when they had received at least 4 diphtheria-tetanus-acellular pertussis/diphtheria-tetanus-pertussis vaccines, 3 poliovirus vaccines, 1 MMR vaccine, 3 Haemophilus influenza vaccines, and 3 hepatitis B vaccines at the time the interview was conducted. Results. Among the 735 children in our study sample, 72% were UTD. The vast majority (94%) reported some type of health insurance at the time of the survey. Children with private insurance were more likely to be UTD (80%) than those with public insurance (56%) or no insurance (64%). In a multivariate analysis that controlled for child's race/ethnicity; household income; maternal age/marital status/educational level; location of usual care; and Special Supplemental Nutrition Program for Women, Infants, and Children participation, insurance was no longer an independent predictor of vaccination. Conclusions. The disparity in vaccination coverage among publicly, privately, and uninsured children is dramatic, underscoring its importance as a marker for underimmunization, despite the multivariate findings. The Vaccines for Children Program, a partnership between public health and vaccination providers who serve uninsured children and those enrolled in Medicaid, is well suited to target and improve vaccination coverage among these vulnerable children. Pediatrics 2004;113:1959-1964; children, insurance status, vaccination, vaccination coverage., ABBREVIATIONS. SCHIP, State Children's Health Insurance Program; NIS, National Immunization Survey; NSECH, National Survey of Early Childhood Health; CDC, Centers for Disease Control and Prevention; UTD, up to date; WIC, [...]

Objectives. This study uses the first national data on well-child care for young children to 1) assess how many children have a specific clinician for well-child care; 2) identify the health insurance, health care setting, and child and family determinants of having a specific clinician; and 3) assess how parents choose pediatric clinicians. Methods. Data from the National Survey of Early Childhood Health (NSECH), a nationally representative survey of health care quality for young children fielded by the National Center for Health Statistics in 2000, were used to describe well-child care settings for children aged 4 to 35 months. Parents reported the child's usual setting of well-child care, whether their child has a specific clinician for well-child care, and selection method for those with a clinician. Bivariate and logistic regression analyses are used to identify determinants of having a specific clinician and of provider selection method, including health care setting, insurance, managed care, and child and family characteristics. Results. Nearly all young children aged 4 to 35 months in the United States (98%) have a regular setting, but only 46% have a specific clinician for well-child care. The proportion of young children who have a single clinician is highest among privately insured children (51%) and lowest among publicly insured children (37%) and uninsured children (28%). In multivariate logistic regression including health care and sociodemographic factors, odds of having a specific clinician vary little by health care setting. Odds are lower for children who are publicly insured (odds ratio [OR]: 0.7; 95% confidence interval [CI]: 0.45-0.97) and for Hispanic children with less acculturated parents (OR: 0.6; 95% Ch 0.39-0.91). Odds are higher for children in a health plan with gatekeeping requirements (OR: 1.4; 95% CI: 1.02-1.88). Approximately 13% of young children with a specific clinician were assigned to that provider. Assignment rather than parent choice is more frequent for children who are publicly insured, in managed care, cared for in a community health center/public clinic, Hispanic, and of lower income and whose mother has lower education. In multivariate logistic regression, only lack of health insurance, care in a community health center, and managed care participation are associated with lack of choice. Conclusions. Anticipatory guidance is the foundation of health supervision visits and may be most effective when there is a continuous relationship between the pediatric provider and the parent. Only half of young children in the United States are reported to have a specific clinician for well-child care. Low rates of continuity are found across health care settings. Furthermore, not all parents of children with a continuous relationship exercised choice, particularly among children in safety net health care settings. These provisional findings on a new measure of primary care continuity for children raise important questions about the prevalence and determinants of continuity. Pediatrics 2004;113:1917-1925; continuity of care, clinician, health services, child health., ABBREVIATIONS. AAP, American Academy of Pediatrics; NSECH, National Survey of Early Childhood Health; PCP, primary care provider; OR, odds ratio; CI, confidence interval. Primary care is defined as provision of [...]

Objective. The purpose of this study was to investigate the predictors and frequency of book-sharing activities in a nationally representative sample of families with young children and to examine the extent to which parents report that pediatric health care providers are addressing early literacy activities. Methods. This study analyzed data from the 2000 National Survey of Early Childhood Health (NSECH), a telephone survey of 2068 parents of children aged 4 to 35 months. Parents were queried about the frequency of reading with their child, whether their pediatric provider discussed reading in the past year, and, if not, whether a discussion of the importance of reading to their child would have been helpful. Descriptive statistics, bivariate analyses, and multivariate logistic regression to identify predictors of daily reading among parents of young children nationally were used. Results. Approximately 52% of young children are reportedly read to every day by a parent. Significant predictors of daily reading include older child's age (19-35 months; odds ratio [OR]: 1.77; 95% confidence interval [CI]: 1.18-2.65, as compared with 4-9 months), maternal education greater than high school (OR: 2.00; 95% CI: 1.24-3.22), greater number of children's books in the home (OR: 1.01; 95% CI: 1.00-1.01), and discussion of reading by the pediatric provider (OR: 1.66; 95% CI: 1.23-2.24). Lower odds of daily reading are found for maternal full-time working status (OR: 0.68; 95% CI: 0.49-0.95), black race/ethnicity (OR: 0.61; 95% CI: 0.41-0.91), Hispanic race/ethnicity (OR: 0.56; 95% CI: 0.37-0.86), Spanish language-dominant parents (OR: 0.37; 95% CI: 0.22-0.62), and >1 child in the household (2 children OR: 0.68, 95% CI: 0.48-0.97; 3 children OR: 0.53, 95% CI: 0.35-0.82). Approximately 37% of parents of young children stated that their child's pediatric provider had not discussed reading with them. Nearly half (47%) of these parents indicated that they would have found such a discussion helpful. Conclusions. Family context and daily reading routines are important for a child's early literacy development. This national study identifies how family characteristics and routines are associated with the family's literacy orientation. The analysis also indicates that a large percentage of parents with young children who do not read daily believe that it would be helpful to discuss the importance of reading with their child's pediatric provider. Pediatrics 2004;113:1944-1951; reading, literacy promotion, health supervision., ABBREVIATIONS. AAP, American Academy of Pediatrics; NSECH, National Survey of Early Childhood Health; PEDS, Parent Evaluation of Developmental Status; MHI-5, 5-item Mental Health Index; OR, odds ratio; CI, confidence interval; [...]

Objective. To examine the use and predictors of different discipline practices by parents of very young children using data from the 2000 National Survey of Early Childhood Health (NSECH). Methods. NSECH is a nationally representative telephone survey of 2068 parents of young children between the ages of 4 and 35 months conducted by the National Center for Health Statistics. The survey includes questions about parents' use of 5 discipline practices: yelling, spanking, time out, toy removal, and explanations. [chi square] analyses and logistic multivariate regression were used to examine associations between discipline practices and child, parent, and demographic factors. Results. Among young children aged 19 to 35 months, frequent parental use of discipline strategies ranged from 26% (spanking) to 65% (taking away toy or treat), 67% (yelling), 70% (using time out), and 90% (providing explanations). In multivariate analyses, child age predicts reports of more frequent spanking and yelling, and child developmental risk is associated with increased reports of yelling. Parent frustration predicts frequent use of every discipline practice, including a greater inclination to use aversive practices. Lower parental emotional well-being is associated with reports of frequent yelling and spanking. Black ethnicity and maternal age predict more frequent spanking, and Spanish-speaking parents reported less frequent use of time out and taking away a toy. Conclusion. Child age and developmental risk and parents' ethnicity, emotions, and mental health are closely associated with discipline practices in the first 3 years of life. These factors are important for pediatricians to recognize in providing anticipatory guidance about discipline. Pediatrics 2004;113:1952-1958; infant, child, parenting, discipline, corporal punishment, anticipatory. guidance., ABBREVIATIONS. AAP, American Academy of Pediatrics; NSECH, National Survey of Early Childhood Health; PEDS, Parents' Evaluation of Developmental Status; MHI-5, Mental Health Index-5; CI, confidence interval; OR, odds ratio. Health [...]

Objective. To describe the content of anticipatory guidance provided to parents of infants and toddlers and to identify primary areas of unmet need as reported by both parents and pediatricians. Methods. Parent data were obtained from the National Survey of Early Childhood Health, a nationally representative sample of parents of 2068 US children aged 4 to 35 months. Pediatrician data were obtained from the Periodic Survey of Fellows, a national survey of members of the American Academy of Pediatrics. Results. Parents and pediatricians tend to agree on the relative ranking of which topics are most frequently addressed. Parents and pediatricians both report that the traditional topics of preventive care--immunizations, feeding issues, and sleep patterns--are most frequently discussed, whereas topics that were more recently introduced into pediatric care related to developmental needs and family context are less commonly addressed. Parent-reported discussion of these topics include reading (discussed for 61% of children 19-35 months) and child care (discussed for 26% of children 19-35 months). Parent reports of some unmet need--defined as topics not discussed that the parent believes would have been helpful to them--affect 36% of children aged 4 to 9 months and 56% of children aged 10 to 35 months and are highest for the topics of discipline strategies and toilet training. Other specific areas of unmet need reported by at least 15% of parents are burn prevention, child care, reading, vocabulary development, and social development. Rates of unmet need vary with family characteristics and health system factors, including maternal education, race/ethnicity, and length of well-child visits. Conclusion. Parents and pediatricians report high rates of discussion on many topics that are critical to healthy development in the first years of life. They also identify areas of need that largely address health supervision on developmental topics. Findings indicate that additional research is needed to understand issues related to specific topic areas as well as the dynamics of personal and system factors that determine what is discussed. Pediatrics 2004;113:1907-1916; children, health supervision, preventive care, anticipatory guidance., ABBREVIATIONS. AAP, American Academy of Pediatrics; NSECH, National Survey of Early Childhood Health. Providing anticipatory guidance during health supervision visits in early childhood is a defining component of pediatric primary [...]

Objectives. The National Survey of Early Childhood Health (NSECH) is a new survey that was designed to provide nationally representative data on the health and development of children and to fill an information gap in the pediatric literature on parents' views of the delivery of health care to their young children. Design. The selection of topics was guided by previous studies conducted to examine parents' expectations and needs in child health supervision visits. The NSECH is a random-digit-dial telephone survey of a nationally representative sample of 2068 children aged 4 to 35 months. This sample includes an oversample of black and/or Hispanic children so that results for these minority groups could be estimated with greater precision. The sampling frame for NSECH is from the State and Local Area Integrated Telephone Survey (SLAITS), which is a program of surveys conducted by the National Center for Health Statistics that makes economical use of the large sampling frame of the National Immunization Survey (NIS). SLAITS takes advantage of the NIS screening effort by fielding interviews on other health topics with households screened for the NIS. The respondent was the parent or guardian identified as the person most responsible for the sampled child's medical care. Spanish-language interviews composed 19% of all completed interviews. The Council of American Survey Research Organizations response rate was 65.6%. Conclusion. The NSECH provides a unique data set that allows a well-rounded picture of the health, health care utilization, health care content, and interpersonal quality of health services received by young children in the United States. It also contains important information about family characteristics, patterns of health-promoting behaviors, and family routines that are associated with promoting the developmental health of young children. NSECH results can also help national policy makers understand the health needs of families with young children and how well the health system is meeting those needs. Pediatrics 2004;113:1899-1906; health surveys, child health, health indicators, health services., ABBREVIATIONS. AAP, American Academy of Pediatrics; NSECH, National Survey of Early Childhood Health; NCHS, National Center for Health Statistics; CDC, Centers for Disease Control and Prevention; SLAITS, State and Local [...]

ABBREVIATIONS. AAP, American Academy of Pediatrics; NSECH, National Survey of Early Childhood Health; MCHB, Maternal and Child Health Bureau; NIS, National Immunization Survey; PHDS, Promoting Healthy Development Survey; DA, developmental [...]

ABBREVIATION. EMS, emergency medical service. For more than 30 years, pediatrics has embraced early child development and school performance at older ages as an integral part of clinical practice. This [...]

THE CASE FOR UNIVERSAL HEALTH-insurance coverage is becoming universally acknowledged. To make a real difference in health outcomes, cost, and system performance, we need to cover the whole person, with [...]

Home visitation by a social worker does not appear to be effective in prompting African-American women in poor communities to bring their babies for a well-child care (WCC) examination. Researchers compared the number of WCC exams among 185 mothers who participated in a case management/home visitation program and 180 who did not. Eighty-one percent of the women in the case management program made at least four WCC visits compared to 70% of those not participating. This modest improvement may not be cost-effective, since home visitation is expensive., Objective. To evaluate a case management/home visitation intervention to improve access to and utilization of well-child care (WCC) visits. Study Design. Randomized, controlled trial with baseline and follow-up interview surveys. Mothers and infants in the intervention group were assigned to a case manager who made at least four home visits during the infant's first year of life. In addition, the case managers contacted clients by telephone and mail to see if they had kept their WCC appointments and to follow up on other issues. Sample and Data Collection. A population-based random sample of African-American mothers of newborns from South Central Los Angeles: 185 mothers in the intervention group and 180 in the control group completed both interview surveys. The principal outcome variable was number of WCC visits. Additional outcome variables included the child's type of insurance, the number of months with insurance coverage during the first year of life, age when first enrolled in Medi-Cal, age at the first WCC visit, usual source of WCC, travel time to the usual source of care, whether the child had a regular provider, and whether the child ever needed care but did not get it. Results. There was little change in the overall distribution of number of WCC visits during the first year of life. Comparisons of the cumulative numbers of visits for each possible cutoff showed that children in the intervention group were more likely than children in the control group to have at least four visits (81% vs 70%). Because this split was identified empirically rather than through an antecedent hypothesis, we conducted a Smirnov test to account for multiple comparisons. This test showed a reduced level of significance. Other outcome variables did not show significant differences for the control and intervention groups. Conclusions. In light of the high expense of this intervention, our evaluation shows that our moderate-intensity case management and home visitation program is not an effective way to increase the number of WCC visits. Pediatrics 1998;101:999-1005; access to care, case management, home visitation, utilization, well-child care., ABBREVIATIONS. WCC, well-child care; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children; SID, standard deviation; OR, odds ratio; CI, confidence interval. Children in poor communities typically face barriers [...]

Objectives. This study provides a current national profile of the prevalence and impact of chronic conditions causing childhood disability. Disability is defined as a long-term reduction in ability to conduct social role activities, such as school or play, because of a chronic physical or mental condition. Methods. A cross-sectional descriptive analysis was performed on data from 99 513 children younger than 18 years who were included in the 1992-1994 National Health Interview Survey. The response rate exceeded 93% during each year. Results. A significant proportion of children, estimated at 6.5% of all US children, experienced some degree of disability. The most common causes of childhood disability were respiratory diseases and mental impairments. Prevalence of disability was higher for older children, boys, and children from low-income and single-parent families. Childhood disability is estimated to result in 66 million restricted activity days annually, including 24 million days lost from school. Furthermore, disability in childhood results in an added 26 million physician contacts and 5 million hospital days annually. Conclusions. Childhood disability has profound impacts on children, the education system, and the health care system. (Am J Public Health. 1998;88:610-617)

Case management to increase childhood immunization rates in inner-city black families may be modestly effective and very expensive. Poor and minority children are less likely to be fully immunized. Researchers randomly assigned 419 infants and their families to receive home visits and support by case managers, or just printed information on vaccination (the control group). About 64% of children receiving case management completed first-year immunizations, compared to 50.6% of children in the control group. Case management cost $12,022 for each additional child who became fully-immunized., Context. -- Immunization rates in the inner city remain lower than in the general US population, but efforts to raise immunization levels in inner-city areas have been largely untested. Objective. -- To assess the effectiveness of case management in raising immunization levels among infants of inner-city, African American families. Design. -- Randomized controlled trial with follow-up through 1 year of life. Setting. -- Low-income areas of inner-city Los Angles Calif. Patients -- A representative sample of 419 African American infants and their families. Interventions. -- In-depth assessment by case managers before infants were 6 weeks of age, with home visit 2 weeks prior to when immunizations were scheduled and additional follow-up visits as needed. Main Outcome Measures. -- Percentage of children with up-to-date immunizations at age 1 year, characteristics associated with improved immunization rates, and cost-effectiveness of case management intervention. Results. -- A total of 365 newborns were followed up to age 1 year. Overall, the immunization completion for the case management group was 13.2 percentage points higher than the control group (63.8% vs 50.6%; P=.01). In a logistic model, the case management effect was limited to the 25% of the sample who reported 3 or fewer well-child visits (odds ratio, 3.43; 95% confidence interval, 1.26-9.35); for them, immunization levels increased by 28 percentage points. Although for the case management group intervention was not cost-effective ($12 022 per additional child immunized), it was better ($4546) for the 25% of the sample identified retrospectively to have inadequate utilization of preventive health visits. Conclusions. -- A case management intervention in the first year of life was effective but not cost-effective at raising immunization levels in inner-city, African American infants. The intervention was demonstrated to be particularly effective for subpopulations that do not access well-child care; however, currently there are no means to identify these groups prospectively. For case management to be a useful tool to raise immunizations levels among high-risk populations, better methods of tracking and targeting, such as immunization registries, need to be developed.

Even though the number of pediatricians per 100,000 children increased substantially between 1982 and 1992, they do not seem to be evenly distributed nationwide. National physician datafiles showed that there were 36% more pediatricians available to a fixed child population size in 1992 compared to 1982. However, these pediatricians tended to cluster in high-income areas and areas with residency opportunities. The ratio of pediatricians to children varied widely between states. Distribution patterns were better for doctors as a whole and for pediatric heart specialists than general pediatricians., Objectives. To determine current geographic distribution of pediatricians in the United States, to assess the changes in the geographic distribution of pediatricians between 1982 and 1992, and to identify factors associated with the distribution of pediatricians among the 50 states. Methods. A data set was constructed using several published data sources including the American Medical Association Physician Masterfile as the principal source for physician information. The pediatrician-to-child population ratio (PCPR, the number of pediatricians per 100 000 people under 18 years of age) was calculated to compare the distribution of pediatricians among states and the distributional changes between 1982 and 1992. Lorenz curves and Gini indices were used to describe distributions and to compare distributions across time periods. Linear regression analysis was performed to assess the relationship between PCPR (dependent variable) with 9 predictor variables. Results. Between 1982 and 1992, there was a 5.4% increase in the United States (US) child population and a 46.1% increase in the number of pediatricians in patient care. During that time period, the PCPR increased by 38.6% from 35.1 per 100 000 to 48.6 per 100 000. There was a more than 4-fold difference in the PCPRs of the highest state (Maryland, 84.3) and the lowest state (Idaho, 18.5) in 1992. The PCPR increased in all 50 states, but varied from a 4.1% increase in Wyoming to a 63.4% increase in Massachusetts. The Lorenz curve showed that pediatricians were less evenly distributed than all physicians, but more evenly distributed than pediatric cardiologists. Between 1982 to 1992 the Gini index decreased 9.8% for all physicians and 10.2% for pediatric cardiologists, but only 1.9% for pediatricians. Since a decrease in the Gini index signifies better overall distribution, these changes are relatively modest for pediatricians as a whole, especially when compared to other physicians. Regression analysis showed that a higher PCPR was associated with a greater number of residency positions per 100 000 children and with the per capita income of the state (R = .93). Conclusions. The distribution of pediatricians does not parallel the distribution of the child population in the US, nor has this distribution changed substantially in spite of a 38.6% increase in the PCPR. Pediatricians tend to concentrate in states with high per capita income and in states with a larger number of residency training positions. The failure of market forces to improve the geographic distribution may require manpower policy changes designed to improve distribution in underrepresented states. The uncertain impact of market changes due to increased use of managed care could affect distributional requirements of pediatricians in the future. Pediatrics 1997;100:172-179; manpower, pediatricians, distribution., ABBREVIATIONS. US, United States; GMENAC, Graduate Medical Education National Advisory Committee; COGME, Council on Graduate Medical Education; AMA, American Medical Association; AHA, American Hospital Association; HMO, health maintenance organization; PPO, [...]

The residency status of immigrant parents in Los Angeles does not seem to affect whether their children are covered by Medicaid but this could change since the passage of California Proposition 187. Prop 187 forbids the provision of health care services to the children of illegal immigrants. Researchers surveyed 817 Latino families in Los Angeles who had children 1 to 3 years old. Only 40% of the children had been covered by Medicaid since birth. However, children of immigrants who were US residents were no more likely to have continuous Medicaid coverage than children of non-residents., Objectives.--To understand the role of parental immigration status on Medicaid enrollment and access to health services for young Latino children. Design.mA cross-sectional household survey of the parents of inner-city Latino children. Setting.--South Central and East Los Angeles, Calif, 1992. Population.--Children 12 to 36 months old and their parents from 817 Latino families. Main Outcome Variables---Continuous Medicaid enrollment, continuity of care, deferral of care, and number of visits. Methods.--Univariate analysis, logistic and linear regression by demographic and socioeconomic characteristics, residency status, and language use. Results.--Children were primarily born in the United States (96%), but most parents were not citizens (80%). Only 40.0% of eligible children had continuous Medicaid coverage since birth, 18.6% had never been insured, and 20.7% had received episodic Medicaid coverage. Continuous Medicaid coverage was negatively associated with either the caregiver (odds ratio [OR],0.32; 95% confidence interval [CI], 0.19-0.56) or their partner (OR=0.33, 95% C1=0.20-0.55) working. Residency status, language preference, and length of US residency were not associated with continuous Medicaid enrollment. Insurance coverage was associated with more physician visits, greater continuity of care, and fewer deferrals of care. Conclusion.--While most (84%) young Latino children in inner-city Los Angeles were eligible for Medicaid, a substantial proportion (39.3%) have episodic or no coverage, Insurance status and provider type wore more consistently associated with access rather than residency and language preference. In the aftermath of California's Proposition 187 and federal welfare reform, insurance status and access are likely to worsen for these young children unless the wave of antiimmigration sentiments is held in check. JAMA 1997;277:636-641

The likelihood of using hospital emergency rooms for sick-child care appears to depend on social factors and the availability of primary care doctors. Researchers analyzed data from a 1988 national sample of 17,700 children under age 18. Black families, single parent families, families with mothers not completing high school, poor families, and urban families were more likely to use the emergency room for sick care. Children living in counties with abundant numbers of primary care physicians were half as likely to use emergency rooms for sick care. Insurance status had no effect., Background. The use of the emergency departments as a regular source of sick care has been increasing, despite the fact that it is costly and is often an inappropriate source of care. This study examines factors associated with routine use of emergency departments by using a national sample of US children. Methods. Data from the 1988 National Health Interview Survey on Child Health, a nationally representative sample of 17 710 children younger than 18 years, was linked to county-level health resource data from the Area Resource File. Bivariate and multivariate analyses were used to assess the association between children's use of emergency departments as their usual sources of sick care and predisposing need and enabling characteristics of the families, as well as availability of health resources in their communities. Results. In 1988 3.4% or approximately 2 million US children younger than 18 years were reported to use emergency departments as their usual sources of sick care. Significant demographic risk factors for reporting an emergency department as a usual source of sick care included black versus white race (odds ratio [OR], 2.08), single-parent versus two-parent families (OR, 1.53), mothers with less than a high school education versus those with high school or more (OR, 1.76), poor versus nonpoor families (OR, 1.76), and living in an urban versus suburban setting (OR, 1.38). Specific indicators of need, such as recurrent health conditions (asthma, tonsillitis, headaches, and febrile seizures), were not associated with routine use of emergency departments for sick care. Furthermore, health insurance status and specifically Medicaid coverage had no association with use of the emergency department as a usual source of sick care. Compared with children who receive well child care in private physicians' offices or health maintenance organizations, children whose sources of well child care were neighborhood health centers were more likely to report emergency departments for sick care (OR, 2.01). Children residing in counties where the supply of primary care physicians was in the top quintile had half the odds (OR, 0.50) of reporting emergency departments as usual sources of sick care. Conclusions. Reliance on hospital emergency departments for routine sick care is strongly associated with demographic and social characteristics of the child and family, the type and source of available well child care, and the supply of primary care physicians. Because health insurance status was not a significant predictor of use, public policies aimed at reducing the use of emergency departments by children will need to address other factors. These include the organizational characteristics and responsiveness of the health care system and the motivation of families for routine use of hospital emergency departments. Pediatrics 1996;98:28-34; emergency department, use, Medicaid, health insurance., ABBREVIATIONS. NHIS-CH, National Health Interview Survey on Child Health; HMO, health maintenance organization; OR, odds ratio; CI, confidence interval; FQHC, federally qualified health center. Although almost all children in the [...]

Purpose: Understanding the full impact of COVID-19 on U.S. children, families, and communities is critical to (a) document the scope of the problem, (b) identify solutions to mitigate harm, and (c) build more resilient response systems. We sought to develop a research agenda to understand the short- and long-term mechanisms and impacts of the COVID-19 pandemic on children's healthy development, with the goal of devising and ultimately testing interventions to respond to urgent needs and prepare for future pandemics. Description: The Life Course Intervention Research Network facilitated a series of virtual meetings that included members of 10 Maternal and Child Health (MCH) research programs, their research and implementation partners, as well as family and community representatives, to develop an MCH COVID-19 Research Agenda. Stakeholders from academia, clinical practice, nonprofit organizations, and family advocates participated in four meetings, with 30–35 participants at each meeting. Assessment: Investigating the impacts of COVID-19 on children's mental health and ways to address them emerged as the highest research priority, followed by studying resilience at individual and community levels; identifying and mitigating the disparate negative effects of the pandemic on children and families of color, prioritizing community-based research partnerships, and strengthening local, state and national measurement systems to monitor children's well-being during a national crisis. Conclusion: Enacting this research agenda will require engaging the community, especially youth, as equal partners in research co-design processes; centering anti-racist perspectives; adopting a "strengths-based" approach; and integrating young researchers who identify as Black, Indigenous, and People of Color (BIPOC). New collaborative funding models and investments in data infrastructure are also needed. [ABSTRACT FROM AUTHOR]