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While family engagement at the individual level of health care, such as families partnering with providers in decision-making about health care for an individual child has been well studied, family engagement in systems-level activities (e.g., participation in advisory and other decision-making groups, or creation and revision of policies) that impact the health services families and children receive has not. This note from the field presents a framework that describes the information and supports that help families partner with professionals and contribute to systems-level activities. Without attention to these components of family engagement, family presence and participation may be only token. We engaged an expert Family/Professional Workgroup whose members represented key constituencies and diverse geography, race/ethnicity, and areas of expertise; conducted a review of peer-reviewed publications and grey literature; and conducted a series of key informant interviews to identify best practices for supporting meaningful family engagement at the systems level. Based on an analysis of the findings, the authors identified four action-oriented domains of family engagement and key criteria that support and strengthen meaningful family engagement in systems-level initiatives. Child- and family-serving serving organizations can use this Family Engagement in Systems framework to support meaningful family engagement in the design of policies, practices, services, supports, quality improvement projects, research, and other systems-level activities.

The American Public Health Association (APHA) policy statements are written by members and approved by the APHA Governing Council. Policy statements inform APHA's position on key public health issues. Maternal and child health (MCH) is a broad discipline focused on health issues concerning women, children, youth, and families. APHA's MCH policies from the last 50 years were reviewed in celebration of the 100th anniversary of the MCH Section of APHA.A cross-sectional design was utilized to identify MCH-related statements within the larger APHA policy statement database from 1970 to 2019 (N = 1,110). The policy statements were coded as primary MCH (main focus was MCH) or secondary MCH (mentioned MCH subpopulations as vulnerable population). The primary MCH themes were also identified.545 (49%) of the APHA policy statements were related to MCH, including 226 (20%) coded as primary MCH and 319 (29%) secondary MCH. The primary MCH policy statements had a main focus on the following subpopulations: women (44%), children (33%), adolescents/young adults (15%), infants (12%), families (5%), and men (2%). Major themes included reproductive health/family planning, school health, children's health, pregnancy/childbirth, and breastfeeding/nutrition.MCH policy statements remained an important part of APHA's policy and advocacy focus over time as indicated through the continuous high number and proportion of MCH policy statements. The historical overview of MCH policy provides insight into critical policy issues confronting the MCH field over the decades and provides guidance for future policy initiatives including a need for increased emphasis on diverse MCH populations.This analysis provides a 50 year overview of MCH themes as viewed by the policy statements published by APHA, the largest public health professional organization in the United States. These policy statements represent the cutting edge of MCH policy efforts and were written to influence national, state, and local public health policy. APHA policy statements should continue to address these important MCH topics in the future with an increased emphasis on diverse MCH populations. APHA policy making is a valuable national professional activity for the MCH field with the goal of improving the health for MCH communities.

The Biden/Harris Administration faces many challenges, from systems and policies that do not work for or benefit all Americans to stark social and political divisions. Multiple courses of action will be necessary, and there must be commitment and investment for the "long haul." When considering the nation's challenges, overarching themes emerge that must be addressed. For instance, recommendations for justice reform cannot be followed without significant focus on race and equity. This focus will also be needed in considering solutions to affordable housing shortages, economic crises, and social and economic immobility concerns. In a similar vein, if the interests and rights of our nation's children are not recognized now, the social consequences will impact every aspect of their livelihoods-and those of future generations. The recommendations put forward by the Global Alliance are bold and will take time to fully implement. The implementation of these recommendations will challenge our systems and our policymakers to acknowledge our past and reenvision the future-and they will help address the multifaceted behavioral health and well-being needs of our nation, its communities, and its people. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Social determinants of health is a concept relevant to parenting in two ways. First, parenting behavior is a social determinant for child health and development; effective parenting is essential for successful emotional, physical and cognitive development. Second, social determinants of health are critical to the development and sustainability of adequate parenting behaviors, which, in term, are a social determinant of child health. Key social determinants related to parenting include economic stability, education, social and community context, neighborhood and built environment, access to health care and parenting interventions, and racism.

A number of programs, policies, and practices have been tested using rigorous scientific methods and shown to prevent behavioral health problems (Catalano et al., Lancet 379:1653–1664, 2012; National Research Council and Institute of Medicine, 2009). Yet these evidence-based interventions (EBIs) are not widely used in public systems, and they have limited reach (Glasgow et al., American Journal of Public Health 102:1274–1281, 2012; National Research Council and Institute of Medicine 2009; Prinz and Sanders, Clinical Psychology Review 27:739–749, 2007). To address this challenge and improve public health and well-being at a population level, the Society for Prevention Research (SPR) formed the Mapping Advances in Prevention Science (MAPS) IV Translation Research Task Force, which considered ways to scale up EBIs in five public systems: behavioral health, child welfare, education, juvenile justice, and public health. After reviewing other efforts to scale up EBIs in public systems, a common set of factors were identified as affecting scale-up in all five systems. The most important factor was the degree to which these systems enacted public policies (i.e., statutes, regulations, and guidance) requiring or recommending EBIs and provided public funds for EBIs. Across systems, other facilitators of scale-up were creating EBIs that are ready for scale-up, public awareness of and support for EBIs, community engagement and capacity to implement EBIs, leadership support for EBIs, a skilled workforce capable of delivering EBIs, and data monitoring and evaluation capacity. It was concluded that the following actions are needed to significantly increase EBI scale-up in public systems: (1) provide more public policies and funding to support the creation, testing, and scaling up of EBIs; (2) develop and evaluate specific frameworks that address systems level barriers impeding EBI scale-up; and (3) promote public support for EBIs, community capacity to implement EBIs at scale, and partnerships between community stakeholders, policy makers, practitioners, and scientists within and across systems.

Mental health needs have been recognized as a priority area by the World Health Organization (WHO), and a Comprehensive Mental Health Action Plan (2013) was proposed to address the needs of millions of people around the world. Concerns have been raised about the degree to which current global efforts are appropriate and sufficient for promoting mental health (MH), reducing the risk for common MH disorders, and addressing the needs of individuals experiencing mental illness. This commentary expands on the presentation of the Global Alliance for Behavioral Health and Social Justice's Task Force on Global Mental Health at the 16th Biennial Conference of the Society for Community Research and Action, held in Ottawa, Ontario, Canada June 21-24, 2017, "Building Capacity to Address Mental Illness and Emotional Distress in Low-Resource Settings and Among Refugee Populations." Utilizing a socioecological framework, this commentary offers a call to action in addressing global mental health by emphasizing the need for greater investments in wellness promotion, prevention, treatment, and recovery. Importantly, such efforts need to value local knowledge and culture, harness natural existing resources and assets, and ensure equitable distribution of key resources for MH. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Advisory Committee on Immunization Practices recommends annual influenza vaccination for all health care personnel (HCP) to reduce influenza-related morbidity and mortality among both HCP and their patients and to decrease absenteeism among HCP. To estimate influenza vaccination coverage among U.S. HCP for the 2014–15 influenza season, CDC conducted an opt-in Internet panel survey of 1,914 HCP during March 31–April 15, 2015. Overall, 77.3% of HCP survey participants reported receiving an influenza vaccination during the 2014–15 season, similar to the 75.2% coverage among HCP reported for the 2013–14 season. Vaccination coverage was highest among HCP working in hospitals (90.4%) and lowest among HCP working in long-term care (LTC) settings (63.9%). By occupation, coverage was highest among pharmacists (95.3%) and lowest among assistants and aides (64.4%). Influenza vaccination coverage was highest among HCP who were required by their employer to be vaccinated (96.0%). Among HCP without an employer requirement for vaccination, coverage was higher for HCP working in settings where vaccination was offered on-site at no cost for 1 day (73.6%) or multiple days (83.9%) and lowest among HCP working in settings where vaccine was neither required, promoted, nor offered on-site (44.0%). Comprehensive vaccination strategies that include making vaccine available at no cost at the workplace along with active promotion of vaccination might help increase vaccination coverage among HCP and reduce the risk for influenza to HCP and their patients.

Pregnant women and infants are at increased risk for influenza-related complications and hospitalization. Influenza vaccination can reduce the risk for influenza-related illness among pregnant women and their infants. Since 2004, the Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists (ACOG) have recommended influenza vaccination for all women who are or will be pregnant during the influenza season, regardless of trimester of pregnancy. To assess influenza vaccination coverage among pregnant women during the 2014–15 influenza season, CDC analyzed data from an Internet panel survey conducted during March 31–April 6, 2015. Among 1,702 survey respondents who were pregnant at any time during October 2014–January 2015, 50.3% reported receiving influenza vaccination before or during pregnancy, similar to the reported coverage in the preceding season. Overall, 64.9% of respondents reported receiving a provider offer of influenza vaccination, 14.8% received a recommendation but no offer, and 20.3% received no recommendation. Vaccination coverage among these groups of women was 67.9%, 33.5%, and 8.5%, respectively. Reminder systems and standing orders that allow health care personnel other than the attending provider to assess vaccination status and administer vaccination, can help to ensure that influenza vaccination is recommended and offered to a pregnant woman at each provider visit to increase pregnant women’s vaccination coverage.

This chapter reviews family systems theory and its applications in program evaluations. It provides the measures available to assess family functioning or family systems outcomes in program evaluations and makes recommendations for their use in program evaluations. The characteristics of healthy families have not been investigated extensively in methodologically sound studies, there is consensus among clinicians and theorists in characterizing normal family function. The challenge to family programs is to capture the shared goals and preferred modes of program strategies while remaining flexible enough to tailor the program for individual families. The major purposes of the evaluation and the resources available for its implementation will dictate the overall design and the choice of specific instruments and techniques. More sophisticated family programs with staff able to conduct an outcome or summative evaluation may want to use family systems outcome measures to assess progress on a particular objective.

Initiated in 1991, the Federal Healthy Start Program includes 105 community-based projects in 39 states, the District of Columbia and Puerto Rico. Healthy Start projects work collaboratively with stakeholders to ensure participants' continuity of care during pregnancy through 2 years postpartum. This evaluation of Healthy Start projects examined relationships between implementation of nine core service and system program components and improvements in birth and project outcomes. Program components and outcomes were examined using data from a 2010 Healthy Start project director (PD) survey (N = 104 projects) and 2009 performance measure data from the Maternal and Child Health Bureau Discretionary Grant Information System (N = 98 projects). We explored bivariate relationships between the nine core program components and (a) intermediate and long-term project outcomes and (b) birth outcomes. We assessed independent associations of implementation of all core program components with birth outcomes, adjusting for project characteristics and activities. In 2010, 57 projects implemented all nine core program components: 104 implemented all five core service components and 69 implemented all four core systems components. Implementation of all core program components was significantly associated with several PD-reported intermediate and long-term project outcomes, but was not associated with singleton low birth weight or infant mortality among participants' infants. This evaluation revealed a mixed set of relationships between Healthy Start projects' implementation of the core program components and achievement of project outcomes. Although the findings demonstrated a positive impact of Healthy Start projects on birth outcomes, only a few associations were statistically significant.

To describe the evolution, accomplishments, and limitations of a research consortium after 25 years of existence. A narrative historical account supplemented by data documenting citations to all group papers. In 1980 the Research Consortium on Children with Chronic Conditions was established. Since then, we have met 2-3 times a year to discuss issues related to research and policies for children with special health care needs. We describe the origin of the Consortium, its operation, and some of its accomplishments, as well as the difficulties it encountered. Our interactions helped promote and sustain research on an emerging topic and did so in an interdisciplinary manner. We include a citation analysis suggesting that group papers published by Consortium members are reasonably well cited by others. We believe our work has been of value in developing influencing research, clinical practice, and policy. This paper is intended to serve as a guide for others who believe that this type of interaction can do much to promote an emerging field. However, it also highlights some of the difficulties in forging and maintaining a productive, research-focused relationship over an extended period of time. The most important lesson learned is that a small group of committed individuals able to meet on a regular basis can accelerate movement in a new field. However, unless stable funding can be secured, maintaining a consortium is truly challenging.

ObjectiveThe present study examines the impact of Health Bucks, a farmers’ market incentive programme, on awareness of and access to farmers’ markets, and fruit and vegetable purchase and consumption in low-income New York City neighbourhoods.DesignThe evaluation used two primary data collection methods: (i) an on-site point-of-purchase survey of farmers’ market shoppers; and (ii) a random-digit-dial telephone survey of residents in neighbourhoods where the programme operates. Additionally, we conducted a quasi-experimental analysis examining differential time trends in consumption before and after programme introduction using secondary Community Health Survey (CHS) data.SettingNew York City farmers’ markets and communities.SubjectsFarmers’ market shoppers (n 2287) completing point-of-purchase surveys in a representative sample of New York City farmers’ markets in 2010; residents (n 1025) completing random-digit-dial telephone survey interviews in 2010; and respondents (n 35 606) completing CHS interviews in 2002, 2004, 2008 and 2009.ResultsGreater Health Bucks exposure was associated with: (i) greater awareness of farmers’ markets; (ii) increased frequency and amount of farmers’ market purchases; and (iii) greater likelihood of a self-reported year-over-year increase in fruit and vegetable consumption. However, our CHS analysis did not detect impacts on consumption.ConclusionsWhile our study provides promising evidence that use of farmers’ market incentives is associated with increased awareness and use of farmers’ markets, additional research is needed to better understand impacts on fruit and vegetable consumption.

Disability is an emerging field within public health; people with significant disabilities account for more than 12% of the US population. Disparity status for this group would allow federal and state governments to actively work to reduce inequities. We summarize the evidence and recommend that observed differences are sufficient to meet the criteria for health disparities: population-level differences in health outcomes that are related to a history of wide-ranging disadvantages, which are avoidable and not primarily caused by the underlying disability. We recommend future research and policy directions to address health inequities for individuals with disabilities; these include improved access to health care and human services, increased data to support decision-making, strengthened health and human services workforce capacity, explicit inclusion of disability in public health programs, and increased emergency preparedness.

This article examines the associations among environmental factors, healthy behaviors, and depression in a sample of adults with major disabilities. When sociodemographics and type and level of disability were controlled, environmental factors (e.g., access to care, contacts with friends, and experience of assault) and risk behaviors (e.g., tobacco use, marijuana use, and physical exercise) were significant correlates of depression. Public health practice and research implications are discussed.

This editorial explains the need for a new name for the American Orthopsychiatric Association (ORTHO). As ORTHO continues their work into the 21st century, they want to better reflect their global membership and focus, increasing the number of partnerships with individuals and organizations, and commitment to a just society. Therefore, ORTHO is changing their name to the Global Alliance for Behavioral Health and Social Justice. It is crucial to underscore that, although the organizations name is changing, the values and principles that inform their work will remain the same. The mission statement of the Global Alliance for Behavioral Health and Social Justice is "to inform policy, practice, and research to prevent behavioral health disorders and to promote conditions to ensure that people with disorders can be full participants in society." (PsycINFO Database Record

Public health researchers and practitioners have begun to recognize the dynamic nature of disability, promote the health of people with disabilities, and develop strategies to prevent secondary conditions among them. To understand the epidemiology of secondary conditions, the authors developed the Massachusetts Survey of Secondary Conditions, a longitudinal study of adults with major disabilities (n = 656) based on a conceptual framework linking disability, mediating factors, and health outcomes. This paper reports baseline data on the number of secondary conditions experienced by survey respondents. Respondents experienced a mean of 5.3 of 17 secondary conditions. More numerous secondary conditions were associated with fair or poor general health and number of days unable to do routine activities. Factors amenable to public health interventions included difficulty with weight and exercise maintenance, tobacco and marijuana use, and experiencing assault. Disability should be a focus in all public health research, policy, and programs.

Objectives: The purpose of the study was to examine the effect of language proficiency on enrollment in a state-sponsored child health insurance program. Methods: 1055 parents of Medicaid-eligible children, who were enrolled in a state-sponsored child health insurance program, were surveyed about how they learned about the state program, how they enrolled their children in the program, and perceived barriers to Medicaid enrollment. We performed weighted χ2 tests to identify statistically significant differences in outcomes based on language. We conducted multivariate analyses to evaluate the independent effect of language controlling for demographic characteristics. Results: Almost a third of families did not speak English in the home. These families, referred to as limited English proficiency families, were significantly more likely than English-proficient families to learn of the program from medical providers, to receive assistance with enrollment, and to receive this assistance from staff at medical sites as compared to the toll-free telephone information line. They were also more likely to identify barriers to Medicaid enrollment related to “know-how”—that is, knowing about the Medicaid program, if their child was eligible, and how to enroll. Differences based on language proficiency persisted after controlling for marital status, family composition, place of residence, length of enrollment, and employment status for almost all study outcomes. Conclusions: This study demonstrates the significant impact of English language proficiency on enrollment of Medicaid-eligible children in publicly funded health insurance programs. Strong state-level leadership is needed to develop an approach to outreach and enrollment that specifically addresses the needs of those with less English proficiency.

Family members can become leaders who are a voice not only for their own family, but also as part of a collective voice to advocate for changes in services, programs, policies, and organizations that benefit all families. Family leadership is important because family leaders can keep the focus on the family experience, providing their own and other family stories, experiences, and perspectives to provide first hand feedback on the best ways of meeting the needs of families and the barriers and challenges that families face along the way. Strong family leaders not only have an impact on Maternal and Child Health (MCH) leadership, they represent a vital part of the MCH workforce. In the past, family leaders ‘‘emerged,’’ either by their own initiative and efforts or from other sectors such as education and early childhood program spheres (special education, Head Start, etc.). Family leaders are a valuable resource to MCH; therefore, as MCH identifies strategies for building the leadership capacity of the current workforce and developing the next generation of leaders, it is essential that the role of family and family leaders be infused in all aspects of MCH leadership development. In addition to family leaders, youth and young adults acting as self-advocates play an important role in MCH programs and policy development. Family leaders have become a vital part of the workforce and will be integral in providing a family-driven response to the changing environment, opportunities and realities that MCH will face in the future. This will require that MCH directors recognize the need to ensure family leaders have the knowledge, skills, confidence, and experience to represent the family perspective. Further, MCH as a field will need to cultivate an environment within programs and practices that embraces family leaders and youth/young adult self-advocates as vital members within the MCH workforce.

A sample of 117 Massachusetts adults with predominately high-level spinal cord injuries (SCIs) report a mean of 6.5 (&#453.0) of 17 secondary conditions in the previous year. Hierarchical multiple regression based on a conceptual framework to examine possible contributing factors shows two independent predictors (P &#104 .05) of a greater number of secondary conditions: These predictors are more difficulty with instrumental activities of daily living (IADLs) and more difficulty with accessing medical care. In addition, three variables marginally predicted (P &#104 0.10) more secondary conditions: inadequate access to transportation, tobacco-smoking, and race (white). The findings highlight the importance of IADL difficulty and access to medical care in relation to secondary conditions among adults with SCI.

Many challenges face us today at the local, national, and global levels in assuring the health and security of all individuals. The population-based prevention focus of public health, which is the practice of social justice, offers an approach and potential solutions to major national and global challenges, such as universal health coverage, military investments, climate change, and women's and children's health. As Martin Luther King Jr stated in 1963, “An injustice anywhere is a threat to justice everywhere.” Today there is much to do at the local to global levels to address these injustices in health and well-being. At this critical time in our country's history, with a forthcoming change in administrations, the challenge for the public health community is to articulate how public health works and to develop the political will to invest in this approach.

PROLOGUE: Children with chronic illnesses pose special challenges for the managed care plans that treat them. As health plans step up their demands for monitoring patient care, children's needs sho...

Objective: Children with chronic health conditions face special issues in their interactions with managed care. These children often require additional and more varied services than do other children. Managed care plans increasingly include these children, especially with the growth of Medicaid managed care. This article examines the special issues facing children with chronic conditions and develops strategies for monitoring their care in managed care settings. Methods: The project staff conducted an extensive review of the research and policy literature related to managed care and the special needs of families with children with chronic conditions. The project also reviewed current and proposed plans of federal, state, and private groups for monitoring and, working with parents and other outside groups, identified key issues to consider in developing monitoring plans. Results: The relative rarity of many childhood conditions and the complex interactions among child, family, and community over time make assessment of their care difficult. We describe these child and family characteristics, outline essential features and domains for monitoring systems, and describe population-based and plan-based monitoring systems to assess managed care for these children and their families. Conclusions: Monitoring for children with chronic conditions in managed care arrangements will require public health agencies and health providers to define populations systematically, assess across a variety of conditions, and monitor several domains central to the health of these families.

Introduction One strategy for lowering the prevalence of obesity is to increase access to and affordability of fruits and vegetables through farmers’ markets. However, little has been documented in the literature on the implementation of such efforts. To address this gap, the Division of Nutrition, Physical Activity, and Obesity (DNPAO) sponsored an evaluation of the New York City Health Bucks program, a farmers’ market coupon incentive program intended to increase access to fresh fruits and vegetables in underserved neighborhoods while supporting local farmers. Methods We conducted a process evaluation of Health Bucks program implementation. We interviewed 6 farmer/vendors, 3 market managers, and 4 program administrators, and collected data on site at 86 farmers’ markets, including surveys of 81 managers and 141 farmer/vendors on their perspectives on promotion and redemption of the incentive coupons; knowledge and attitudes regarding the program; experiences with markets and products; and facilitators and barriers to program participation. Results Results indicate that respondents view Health Bucks as a positive program model. Farmers’ market incentive coupon programs like Health Bucks are one strategy to address the problem of obesity and were associated with higher fruit and vegetable access and purchases in low-income communities. Conclusions This evaluation identified some areas for improving implementation of the Health Bucks program. Farmers’ market incentive programs like Health Bucks may be one avenue to increase access to and affordability of fruits and vegetables among low-income persons. Further research is needed to assess the potential effects of these programs on access and health outcomes.

Although “population health” is one of the Institute for Healthcare Improvement’s Triple Aim goals, its relationship to accountable care organizations (ACOs) remains ill-defined and lacks clarity as to how the clinical delivery system intersects with the public health system. Although defining population health as “panel” management seems to be the default definition, we called for a broader “community health” definition that could improve relationships between clinical delivery and public health systems and health outcomes for communities. We discussed this broader definition and offered recommendations for linking ACOs with the public health system toward improving health for patients and their communities.

Objective. Children with chronic illnesses and disabilities are increasingly enrolling in managed care arrangements. Yet, the rapid expansion of managed care has unknown consequences for children with chronic conditions and disabilities. As managed care is likely to become the predominant mode of medical practice for children with chronic health problems, information gained from a thorough assessment of existing managed care models could be helpful in indicating adjustments and modifications that could result in improved outcomes for this population. The purpose of this article is to outline a new strategy for collecting needed information on the effects of managed care on children with chronic health problems. Methods. We reviewed the literature on the effects of managed care on children with chronic conditions and disabilities. We identified key domains relevant to monitoring and evaluating managed care for this population. Results. Two research approaches can provide helpful information for assessing the effects of managed care on children with chronic conditions. First, a monitoring strategy could be pursued in which enrollment trends in managed care, enrollee perceptions of access and satisfaction with care, and other general indicators of outcomes would be tracked over time using inexpensive and rapid turnaround data sources. Second, an evaluative strategy could be pursued using experimental or quasiexperimental designs, in which outcomes across a variety of domains for children with chronic conditions in managed care are compared with: (a) outcomes for the same children before enrollment in managed care; or (b) outcomes for similar children remaining in traditional fee-for-service settings. Evaluation and monitoring strategies should focus on outcomes in a number of domains including: (1) access to care; (2) utilization of services; (3) quality of care; (4) satisfaction with care; (5) expenditures for care; (6) health outcomes; and (7) family impact. Conclusion. Assessing outcomes that result from enrollment in managed care for children with chronic health problems presents a formidable challenge. The research strategy outlined in this article presents one approach to meeting that challenge. The monitoring and evaluation strategies described here would require commitment of additional resources on the part of government, private foundations, and/or health plans. Given the paucity of existing information and the stakes for children with chronic conditions and their families, investment of added resources in a comprehensive monitoring and evaluation strategy is essential.

The past decade has witnessed major accomplishments in the development and application of an operational definition of children with special health care needs (CSHCN) that can now be used to identify these children and youth for systems-level planning as well as individualized care planning in clinical or health plan settings. Researchers, clinicians, and state and federal health policy leaders have sought strategies for assessing the prevalence and impact of chronic conditions and special health care needs among children and youth so that care can be monitored and the quality of care-delivery systems improved over time. The landmark Surgeon General Conference, Campaign ’87, described the principles of family-centered, culturally competent, coordinated, community-based, and comprehensive care in developing integrated systems of care for children and youth with special health care needs and their families.1 Widespread acceptance of these principles also promoted the formal adoption of new nomenclature. The phrase ‘‘children with special health care needs’’ came into use in federal legislation and in state and community service systems to describe a population of children who had formerly been identified as ‘‘crippled,’’ ‘‘handicapped,’’ ‘‘disabled,’’ or ‘‘chronically ill.’’ This broad and inclusive new classification was embraced by policy makers, providers, and family advocates as a way of uniting a diverse group of children with a range of conditions.2 The new population-based approach allowed a larger constituency to focus on a shared set of needs for improved systems of care. The new name and a set of principles for building systems of care were codified in the Omnibus Budget Reconciliation Act of 1989, which authorizes services for this population through Title V of the Social Security Act and the Maternal and Child Health Block Grant program in all states and territories.3,4 An operational definition and tools for applying the new def

Objectives We conducted a pilot study of the Integrated Vaccine Surveillance System (IVSS), a novel active surveillance system for monitoring influenza vaccine adverse events that could be used in mass vaccination settings. Methods We recruited 605 adult vaccinees from a convenience sample of 12 influenza vaccine clinics conducted by public health departments of two U.S. metropolitan regions. Vaccinees provided daily reports on adverse reactions following immunization (AEFI) using an interactive voice response system (IVR) or the internet for 14 consecutive days following immunization. Followup with nonrespondents was conducted through computer-assisted telephone interviewing (CATI). Data on vaccinee reports were available real-time through a dedicated secure website. Results 90% (545) of vaccinees made at least one daily report and 49% (299) reported consecutively for the full 14-day period. 58% (315) used internet, 20% (110) IVR, 6% (31) CATI, and 16% (89) used a combination for daily reports. Of the 545 reporters, 339 (62%) reported one or more AEFI, for a total of 594 AEFIs reported. The majority (505 or 85%) of these AEFIs were mild symptoms. Conclusions It is feasible to develop a system to obtain real-time data on vaccine adverse events. Vaccinees are willing to provide daily reports for a considerable time post vaccination. Offering multiple modes of reporting encourages high response rates. Study findings on AEFIs showed that the IVSS was able to exhibit the emerging safety profile of the 2008 seasonal influenza vaccine.

Site visits were conducted for the evaluation of the national Healthy Start program to gain an understanding of how projects design and implement five service components (outreach, case management, health education, depression screening and interconceptional care) and four system components (consortium, coordination/collaboration, local health system action plan and sustainability) as well as program staff's perceptions of these components' influence on intermediate outcomes. Interviews with project directors, case managers, local evaluators, clinicians, consortium members, outreach/lay workers and other stakeholders were conducted during 3-day in-depth site visits with eight Healthy Start grantees. Grantees reported that both services and systems components were related to self-reported service achievements (e.g. earlier entry into prenatal care) and systems achievements (e.g. consumer involvement). Outreach, case management, and health education were perceived as the service components that contributed most to their achievements while consortia was perceived as the most influential systems component in reaching their goals. Furthermore, cultural competence and community voice were overarching project components that addressed racial/ethnic disparities. Finally, there was great variability across sites regarding the challenges they faced, with poor service availability and limited funding the two most frequently reported. Service provision and systems development are both critical for successful Healthy Start projects to achieve intermediate program outcomes. Unique contextual and community issues influence Healthy Start project design, implementation and reported accomplishments. All eight projects implement the required program components yet outreach, case management, and health education are cited most frequently for contributing to their perceived achievements.

According to a substantial literature, passive smoking by children is associated with an increased incidence of lower respiratory illness and diminished pulmonary function. The relationship between passive smoking and childhood asthma, however, is not clear. Data from the Child Health Supplement to the 1981 National Health Interview Survey were analyzed with information about 4331 children aged 0 to 5 years to study the relationship between maternal smoking and (1) the prevalence of childhood asthma, (1) the likelihood of taking asthma medication, (3) the age of onset of children's asthma, and (4) the number of hospitalizations among children with and without asthma. An odds ratio for asthma of 2.1 was shown by multivariate logistic regressions among children whose mothers smoke 0.5 packs of cigarettes or more per day compared with children of nonsmokers (P = .001). In similar analyses maternal smoking of 0.5 packs per day was identified as an independent risk for children's use of asthma medications (odds ratio 4.6, P = .0006) and for asthma developing in the first year of life (odds ratio 2.6, P = .0006). Maternal smoking is also associated with increased numbers of hospitalizations by its association with an increased risk of asthma as well as by contributing to hospitalizations independently of a child having asthma. Among children with asthma, however, maternal smoking is not associated with increased numbers of hospitalizations. It was concluded that maternal smoking is associated with higher rates of asthma, an increased likelihood of using asthma medications, and an earlier onset of the disease. These findings have implications for renewed efforts to discourage smoking in families, especially during pregnancy and the first 5 years of children's lives.

This article provides a comprehensive overview of the first decade of the Massachusetts Tobacco Control Program (MTCP). Born after Massachusetts passed a 1992 ballot initiative raising cigarette excise taxes to fund the program, MTCP greatly reduced statewide cigarette consumption before being reduced to a skeletal state by funding cuts. The article describes the program's components and goals, details outcomes, presents a summary of policy accomplishments, and reviews the present status of MTCP in the current climate of national and state fiscal crises. The first decade of the MTCP offers many lessons learned for the future of tobacco control.

Current research suggests that people with disabilities are more likely to use tobacco, less likely to quit, and less likely to be screened for tobacco use. However, little is known about the impact of changes in smoking status on the health-related quality of life (HRQL) of people with disabilities.The primary objective of this paper is to examine the association between changes in HRQL and smoking status over time among people with disabilities.The study data were derived from the Massachusetts Survey of Secondary Conditions, a longitudinal survey of adults with disabilities; Phase I was conducted in 1996-1998, Phase II in 1998-1999, and Phase III in 1999-2000. The main outcome measure was HRQL as measured by the Medical Outcomes Study Short Form-36 (SF-36). Analysis was primarily done in 2003.Current smokers and those who began smoking during follow-up had significantly poorer HRQL compared with nonsmokers with disabilities. Longitudinal analysis suggests that controlling for age, gender, race/ethnicity, education, and activities of daily living, changes in HRQL scores over time were associated with changes in smoking status. Compared to smokers, those who quit smoking during follow-up experienced a significant improvement in mean SF-36 scores over time for the dimensions of mental health, energy and vitality, and general health.Findings from this study highlight a strong need to inform public health programs, people with disabilities and healthcare providers about the association between tobacco cessation and improved health-related quality of life among people with disabilities.

This article explores factors that facilitate or impede data sharing and linkage collaborations between state public health agencies and managed care organizations (MCOs). The exploration is based upon a review of both recent literature and the four years' experience of the Massachusetts Health Assessment Partnership (MHAP). MHAP has undertaken six collaborative data sharing and linkage projects that have involved diverse topics and methods. This article summarizes both exogenous and endogenous factors that have affected MHAP as a successful collaboration and indicates those factors that might be replicated in future collaborations between public health agencies and MCOs in other locations.

Health care reform may well address many of the needs of children and adolescents, offering greater emphasis on prevention and providing insurance to the large number of US children currently uninsured. Yet key public health and community health service programs essential to the well being of children and adolescents have gained little attention in the current national health care reform debates. Most discussions focus on insurance and cost containment and fail to address other systemic barriers to health care. Insurance alone will not solve the health problems faced by children and adolescents. SPECIAL NEEDS OF CHILDREN AND ADOLESCENTS Addressing the health risks that children and adolescents face requires combining public and private efforts and community-oriented and personal care services.

The purpose of the study was to examine the effect of language proficiency on enrollment in a state-sponsored child health insurance program.1055 parents of Medicaid-eligible children, who were enrolled in a state-sponsored child health insurance program, were surveyed about how they learned about the state program, how they enrolled their children in the program, and perceived barriers to Medicaid enrollment. We performed weighted chi2 tests to identify statistically significant differences in outcomes based on language. We conducted multivariate analyses to evaluate the independent effect of language controlling for demographic characteristics.Almost a third of families did not speak English in the home. These families, referred to as limited English proficiency families, were significantly more likely than English-proficient families to learn of the program from medical providers, to receive assistance with enrollment, and to receive this assistance from staff at medical sites as compared to the toll-free telephone information line. They were also more likely to identify barriers to Medicaid enrollment related to "know-how"--that is, knowing about the Medicaid program, if their child was eligible, and how to enroll. Differences based on language proficiency persisted after controlling for marital status, family composition, place of residence, length of enrollment, and employment status for almost all study outcomes.This study demonstrates the significant impact of English language proficiency on enrollment of Medicaid-eligible children in publicly funded health insurance programs. Strong state-level leadership is needed to develop an approach to outreach and enrollment that specifically addresses the needs of those with less English proficiency.

Parents of children with a wide variety of chronic health conditions (N = 910) were surveyed about their use of health services, out-of-pocket expenses for health care and related items, and ratings of the importance of health and support services. The financial burden on this middle-class, insured sample was substantial, with about half indicating some out-of-pocket expenses for travel, parking fees, drugs and medication, bills after insurance payments, and doctor charges. The commonalities found in parents' reporting of important services needed support the use of a noncategorical approach to program planning and policy development for children with special health care needs.

Objective. In an era when expanding publicly funded health insurance to children in higher income families has been the major strategy to increase access to health care for children, it is important to determine if the benefits to higher income children attributable to the receipt of health coverage are similar to those observed for lower income children. This study investigated how the likely impact of child health insurance expansions varies with family income. Methods. We surveyed parents or guardians of children who were enrolled in a state-sponsored health insurance program (Massachusetts Children’s Medical Security Plan [CMSP]) that, before the implementation of the State Children’s Health Insurance Plan (SCHIP), was open to all children regardless of income. A stratified sample of children was drawn from administrative files. We grouped children by income category (low-income [LI]: ≤133% of the federal poverty limit [FPL], middle-income [MI]: 134%–200% of the FPL, high-income [HI]: >200% of the FPL) that corresponded to eligibility for public health insurance programs in the state (Medicaid-eligible, SCHIP-eligible, and income that exceeded SCHIP eligibility). The majority of telephone interviews were conducted between November 1998 and March 1999. The overall response rate was 61.8%, yielding a sample of 996 children. The CSMP benefit package included comprehensive coverage for preventive and specialty care and limited coverage for ancillary services. Children enrolled in CMSP were not covered for inpatient hospital stays but those whose family income was We used survey responses to develop 2 sets of indicators: the first for reported need for services and the second for unmet need or delays in care among children whose parents reported a need for the service. Within each set, we created indicators for 5 types of service (medical care, dental care, prescription drugs, vision services, and mental health care) and an additional composite indicator. The composite indicator aggregated all categories of services covered under CMSP in a single measure; it included all services except dental services, which, at the time of the study, were not covered by the program. The composite indicator served as the dependent variable in regression models. We used weighted χ2 tests to identify statistically significant differences in reported need and unmet need for the 5 types of medical services and the aggregate measure of all services covered by CMSP. We examined differences across income groups at 2 points in time: during the period children were uninsured before enrollment and while enrolled. We used weighted logistic regression to assess the independent association of family income with our dependent variables: reported need for health services and the presence of unmet need, controlling for other covariates. To evaluate the impact of participation in a child health insurance program, we examined unmet need before and after program enrollment, testing for statistical significance using McNemar’s test for within-subject changes. Results. During the period of uninsurance before enrollment, prescription drugs (70%) was the health service needed most frequently, followed by medical (65%) and dental (57%) care. For the composite measure of services covered by CMSP, reported need for services was not significantly different by income. Need for medical care, dental care, and prescription drugs were significantly greater among children who had been uninsured for >6 months before enrollment. In addition, a significantly greater proportion of adolescent participants needed dental, vision, and mental health services than younger enrollees. While enrolled, among recently enrolled children, 77% need medical services, 68% prescription drugs, and 59% dental. In unadjusted models MI and HI children were more than 2 times as likely to report need for covered services as LI children. After adjusting for possible confounders, the effect of income was no longer significant. Instead, nonadolescents (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25–4.76) and children with white ethnicity (OR: 3.03; 95% CI: 1.43–6.67) were significantly more likely to report need for services. Before enrollment, unmet need among those who reported need for services was 5% for medical, 4% prescription drugs, 31% dental, 30% vision, and 33% mental health. For the composite measure of services covered by CMSP, LI children were significantly more likely to have had unmet need before enrollment than MI and HI children (20%, 10%, 7% by income). As compared with younger children, adolescents also had significantly greater unmet need for the composite measure (19% vs 10%). In multivariate models, not having a usual site of care was a highly significant predictor of unmet need or delayed care (OR: 3.41; 95% CI: 1.28–9.11). Ninety-eight percent of parents cited cost as the reason they had difficulty obtaining needed care. After enrollment, the proportion of children who needed care and had difficulty obtaining it decreased for all categories of care. Less than 1% of enrollees reported unmet need or delays in care for medical services and 3% for prescription drugs. Children who needed vision and mental health services continued to experience difficulty obtaining these services (17% for each category of care), although they were covered as part of the benefit package. Unmet need or delays in care for dental services, which at the time of the study were not covered under CMSP, remained high (27%). We found a significant reduction in unmet need among children in all income groups and no significant differences in unmet need by income. Controlling for other covariates, adolescents (OR: 3.11; 95% CI: 1.58–6.12) and children with compromised health (OR: 3.20; 95% CI: 1.35–7.58) were more likely to have had difficulty obtaining needed services while enrolled in the program. Children in larger families (OR: 0.40; 95% CI: 0.17–0.96) and who were previously uninsured for >6 months (OR: 0.45; 95% CI: 0.22–7.58) were less likely to have difficulty obtaining care. Conclusion. Our findings demonstrate the positive impact of providing health insurance coverage to children regardless of income. The HI children who enrolled in the program looked similar to children with incomes that meet current SCHIP eligibility guidelines, suggesting that expansions of SCHIPs to HI children should not qualitatively change the program dynamics.

Background The Questionnaire for Identifying Children With Chronic Conditions (QuICCC) is an instrument based on a conceptual noncategorical definition that uses parental responses to identify children with chronic conditions for epidemiological purposes. Objectives To determine whether the QuICCC is sufficiently valid, sensitive, and specific to be used to identify individual children as having a chronic condition or disability; whether parents are accurate enough that their answers to QuICCC items can be accepted as valid; and what kinds of errors in classification occur when the QuICCC is used to identify children with chronic conditions. Methods The sample consisted of 424 children who were patients of 9 physicians in separate practice settings throughout New England. Each physician was briefly trained in the conceptual definition on which the QuICCC is based and then was asked to identify 25 children in his or her practice who met the definition and 25 children who did not meet the definition. The QuICCC was administered to the parents of these children by blinded interviewers via telephone. The QuICCC classification was compared with physician categorization. Discrepant cases were then followed up by asking physicians and parents to answer the original questions a second time. Results Complete data were available on 379 (89.4%) of 424 children. There was agreement on 89% (κ=0.78). The sensitivity was 94%; specificity, 83%; positive predictive value, 86%; and negative predictive value, 92%. Of the 42 discordant cases, 30 parent reports on the QuICCC qualified the child as having a chronic condition when the physician classified the child as being without such a condition. Fewer (n=12) discrepancies occurred because physicians identified children with chronic conditions that the QuICCC failed to identify. When the questions were readministered at follow-up, physicians corrected errors in rating in 9 cases; mothers changed their answers in 5 instances. In 13 instances the issues were known to both parties and appeared to arise in the "gray zone" or boundary area, where there was disagreement over whether a particular child qualified using the theoretical definition. For 11 children identified as having a chronic condition only by the parent's responses to the QuICCC, physician report appeared to be inaccurate primarily due to the physician's lack of information. In 3 cases where the physician reported the child to have a chronic condition, but the parent did not, the physician appeared to be correct. Follow-up data were incomplete on 1 child. Conclusions These data support the validity of parent-generated information for the evaluation of health status. Although these findings should be replicated, this study suggests that the QuICCC may be applicable also as a screening tool for individual child identification, provided that several sources of error are considered.