Poverty and child health

A Broad-Based Approach to Social Needs Screening in a Pediatric Primary Care Network

OBJECTIVE

In 2016, the American Academy of Pediatrics recommended universally screening patients for social needs, and in 2018, a quality measure for social needs screening was included in some Massachusetts Medicaid contracts. However, exact guidelines for screening were not provided. We describe the results and implications from a broad-based health-related social needs (HRSN or "social needs") screening program within our large, pediatric primary care network.

METHODS

We adapted items from The Health Leads toolkit to create our network's screening tool: The Health Needs Assessment (HNA). We trained staff to use the tool and provided staff with resources to assist families with their needs. All patients with a primary care physician in the network were eligible to complete an HNA. We calculated descriptive statistics and estimated the risk of identifying a social need using multivariable regression analyses.

RESULTS

Between June 2018 and May 2019, 100,097 patients completed an HNA; 8% of patients identified a social need, and 33% of those patients requested assistance with the need(s). The multivariate analysis revealed an association between several patient characteristics-health insurance type, age, median household income by zip code, complex chronic conditions, race/ethnicity-and identifying a social need.

CONCLUSIONS

Our large, pediatric primary care network successfully instituted a broad-based HRSN screening program in response to state and national screening recommendations. We observed a low prevalence of reported social needs and a propensity to forego assistance. Additional research is needed to understand the barriers around the disclosure of social needs and requests for assistance.

A New Paradigm for Addressing Health Disparities in Inner-City Environments: Adopting a Disaster Zone Approach

Inner cities are characterized by intergenerational poverty, limited educational opportunities, poor health, and high levels of segregation. Human capital, defined as the intangible, yet integral economically productive aspects of individuals, is limited by factors influencing inner-city populations. Inner-city environments are consistent with definitions of disasters causing a level of suffering that exceeds the capacity of the affected community. This article presents a framework for improving health among inner-city populations using a multidisciplinary approach drawn from medicine, economics, and disaster response. Results from focus groups and photovoice conducted in Milwaukee, WI are used as a case study for a perspective on using this approach to address health disparities. A disaster approach provides a long-term focus on improving overall health and decreasing health disparities in the inner city, instead of a short-term focus on immediate relief of a single symptom. Adopting a disaster approach to inner-city environments is an innovative way to address the needs of those living in some of the most marginalized communities in the country.

Assessing Child Health and Health Care in the U.S. Virgin Islands Using the National Survey of Children's Health

OBJECTIVES

To characterize the health and health care experiences of children in the U.S. Virgin Islands (USVI), assess differences by household poverty status, and provide comparisons to the general U.S. child population.

METHODS

Data are from the 2011-2012 National Survey of Children's Health, which included 2342 USVI children, aged 0-17 years. Parent-reported measures of health status and health conditions, behavioral characteristics, and health care access and utilization were assessed. Weighted prevalence estimates were calculated and compared by household poverty status using Chi square tests.

RESULTS

Overall, 31.3% of USVI children lived in households below 100% of the federal poverty level (FPL). Children in these low-income households were more likely to have public insurance (33.0% vs. 8.4%) and unmet health needs (11.6% vs. 6.3%) as compared to those in households with incomes ≥ 100% FPL (all p < 0.01). They were also less likely to have a medical home (22.5% vs. 42.2%), including a usual source of sick care (p < 0.01). Compared with U.S. children in general, USVI children had lower rates of preventive medical visits, preventive dental visits, and care received in a medical home.

CONCLUSIONS

USVI children experience challenges in accessing and utilizing health care services, particularly those in low-income households, and fare worse than U.S. children on many of these measures. These findings will serve as a baseline comparison for an upcoming survey of maternal and child health to be conducted in eight U.S. territories including the USVI.

South African, urban youth narratives: Resilience within community

South African youth in low-income, urbanized communities are exposed to high levels of daily stressors, which increase their risk to negative outcomes. Resiliency can provide avenues for youth to transcend adversity and may contribute to their positive development. To provide a deeper understanding of the pathways that adolescents use to overcome adversity, this paper examined future aspirations of South African youth, and how these aspirations were connected to resiliency factors framed by their lived context. A phenomenological approach was used to explore the perceptions of high school students. Fourteen focus groups with girls and boys (N=112) were conducted. Data was analyzed using a thematic approach. Discussions of the harsh conditions undermining the community's future highlighted opportunities for improvement. Community connectedness, hope and altruism were prevalent in youth's responses and could be used to facilitate community and individual resiliency. Our overall findings have important implications for positive youth development efforts.

Portrait of socio-economic inequality in childhood morbidity and mortality over time, Québec, 1990-2005

AIM

To determine the age and cause groups contributing to absolute and relative socio-economic inequalities in paediatric mortality, hospitalisation and tumour incidence over time.

METHODS

Deaths (n= 9559), hospitalisations (n= 834,932) and incident tumours (n= 4555) were obtained for five age groupings (<1, 1-4, 5-9, 10-14, 15-19 years) and four periods (1990-1993, 1994-1997, 1998-2001, 2002-2005) for Québec, Canada. Age- and cause-specific morbidity and mortality rates for males and females were calculated across socio-economic status decile based on a composite deprivation score for 89 urban communities. Absolute and relative measures of inequality were computed for each age and cause.

RESULTS

Mortality and morbidity rates tended to decrease over time, as did absolute and relative socio-economic inequalities for most (but not all) causes and age groups, although precision was low. Socio-economic inequalities persisted in the last period and were greater on the absolute scale for mortality and hospitalisation in early childhood, and on the relative scale for mortality in adolescents. Four causes (respiratory, digestive, infectious, genito-urinary diseases) contributed to the majority of absolute inequality in hospitalisation (males 85%, females 98%). Inequalities were not pronounced for cause-specific mortality and not apparent for tumour incidence.

CONCLUSIONS

Socio-economic inequalities in Québec tended to narrow for most but not all outcomes. Absolute socio-economic inequalities persisted for children <10 years, and several causes were responsible for the majority of inequality in hospitalisation. Public health policies and prevention programs aiming to reduce socio-economic inequalities in paediatric health should account for trends that differ across age and cause of disease.

Material hardship and the physical health of school-aged children in low-income households

OBJECTIVES

We examined the relationship between material hardship reported by low-income caregivers and caregivers' assessments of their children's overall health.

METHODS

We used logistic regression techniques to analyze data from 1073 children aged 5 through 11 years whose caregivers participated in multiple waves of the Illinois Families Study.

RESULTS

Caregivers' reports of food hardship were strongly associated with their assessments of their children's health. Other sources of self-reported material hardship were also associated with caregivers' assessments of their children's health, but the effects disappeared when we controlled for caregiver physical health status and mental health status. Proximal measures of material hardship better explained low-income children's health than traditional socioeconomic measures. There were no statistically significant cumulative effects of material hardships above and beyond individual hardship effects.

CONCLUSIONS

Our findings highlight the importance of developing and supporting programs and policies that ensure access to better-quality food, higher quantities of food, and better living conditions for low-income children, as well as health promotion and prevention efforts targeted toward their primary caregivers as ways to reduce health disparities for this population.

The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children

BACKGROUND AND OBJECTIVE

Fifty-five million Americans speak a non-English primary language at home, but little is known about health disparities for children in non-English-primary-language households. Our study objective was to examine whether disparities in medical and dental health, access to care, and use of services exist for children in non-English-primary-language households.

METHODS

The National Survey of Childhood Health was a telephone survey in 2003-2004 of a nationwide sample of parents of 102 353 children 0 to 17 years old. Disparities in medical and oral health and health care were examined for children in a non-English-primary-language household compared with children in English- primary-language households, both in bivariate analyses and in multivariable analyses that adjusted for 8 covariates (child's age, race/ethnicity, and medical or dental insurance coverage, caregiver's highest educational attainment and employment status, number of children and adults in the household, and poverty status).

RESULTS

Children in non-English-primary-language households were significantly more likely than children in English-primary-language households to be poor (42% vs 13%) and Latino or Asian/Pacific Islander. Significantly higher proportions of children in non-English-primary-language households were not in excellent/very good health (43% vs 12%), were overweight/at risk for overweight (48% vs 39%), had teeth in fair/poor condition (27% vs 7%), and were uninsured (27% vs 6%), sporadically insured (20% vs 10%), and lacked dental insurance (39% vs 20%). Children in non-English-primary-language households more often had no usual source of medical care (38% vs 13%), made no medical (27% vs 12%) or preventive dental (14% vs 6%) visits in the previous year, and had problems obtaining specialty care (40% vs 23%). Latino and Asian children in non-English-primary-language households had several unique disparities compared with white children in non-English-primary-language households. Almost all disparities persisted in multivariable analyses.

CONCLUSIONS

Compared with children in English-primary-language households, children in non-English-primary-language households experienced multiple disparities in medical and oral health, access to care, and use of services.

Medical training in child maltreatment

Training of medical professionals about child maltreatment may provide useful insights into the means of incorporating violence detection and prevention into healthcare practice. Despite major progress since Caffey and Kempe identified child abuse as a medical issue, more needs to be done to ensure that proper recognition, diagnostic, and reporting strategies are used when faced with the possible abuse and neglect of children. Systematic data concerning training programs are lacking. The perceived needs include more consistent education for medical professionals, more federal support for clinical research funding, higher reimbursement rates from third-party payers for clinical care for maltreated children, board certification for doctors who want to specialize in this field, and medical licensure requirements for continuing education in child and family violence. It is clear that interpersonal violence, whether it is child maltreatment, intimate partner violence, or elder abuse, is a significant public health problem in the United States, requiring support for the education and training of medical professionals.

Physical and behavioral health of Medicaid children in two southern states

OBJECTIVES

As the primary insurer of children in the United States, Medicaid covers at least one in four US children. Information on the health and behavioral health needs of this group of children is critical to plan, deliver, and monitor services accordingly.

METHODS

Parent interview data from a representative sample of Medicaid children in two Southern states were used to generate information from standardized questionnaires on physical health status, chronic illnesses, physical functioning, emotional and behavioral symptoms, and psychosocial functioning.

RESULTS

The levels of physical and behavioral health and co-occurring problems were higher than other estimates available on the general population.

CONCLUSIONS

The high levels of health problems among Medicaid-enrolled children need attention in the current struggles over Medicaid reform. Support for improving screening, referral, and integration of services is discussed, as well as the importance of monitoring service system performance in this era of managed care.

Factors associated with variations in parental social support in primary care pediatric settings

OBJECTIVE

To examine social support (SS) among parents across sociodemographically distinct pediatric outpatient settings.

METHODS

We conducted a cross-sectional, self-administered, anonymous parent survey in 3 primary care sites in a Midwestern metropolitan area: inner-city health center, urban group practice, and suburban group practice. Participants were parents of children aged 6 weeks to 36 months. The main outcome measure was overall SS as measured by a previously validated 10-item instrument. Multivariate linear regression modeling was used to examine sociodemographic and health factors associated with overall SS scores.

RESULTS

The study sample included 463 parents. The strongest sources of SS were a significant other or spouse and parent's parent or grandparent. The range for overall SS was 0 to 20, with a mean score of 12.1 (SD, +/-4.2). Parents with overall SS in the lowest quartile (n = 123) comprised 43% of parents at the inner-city health center compared with 23% of parents at the urban practice and 16% of parents at the suburban practice. In a multivariate model, factors associated with lower overall SS were race other than white or black, single or cohabiting marital status, poorer parental health, and parental depressive symptoms.

CONCLUSIONS

Although parental SS was lowest in the most socioeconomically disadvantaged community in this sample, parents in all 3 communities had widely varying levels of support. Providers may gain insights about parents at increased risk for low SS by asking about parents' own physical and mental health.

Changes in the association of low birth weight with socioeconomic status in Hawaii: 1970-1990

This study examines rates of low birth weight (LBW) in the state of Hawaii and changes in the association of LBW with socioeconomic status from 1970 to 1990. The analysis is based on aggregate data for census tracts. Rates of low birth weight were calculated for each census tract. Relative socioeconomic scores were calculated from average household income and years of education. The results show that (1) there was a decrease in the rate of low birth weight infants in Hawaii; and (2) that the correlation between socioeconomic status and low birth weight was substantially reduced, though a significant correlation remains. The paper suggests likely ceiling effects, but that the progressive public health policies and expansion of access to primary health care in Hawaii during this period played a major role in reducing the rate of low birth weight infants and in decreasing socioeconomic inequality on this important health indicator.

Newborn early discharge revisited: are California newborns receiving recommended postnatal services?

CONTEXT

Responding to safety concerns, federal and state legislation mandated coverage of minimum postnatal stays and state legislation in California mandated coverage of follow-up after early discharge. Little is known about the postnatal services newborns are receiving.

OBJECTIVE

To describe rates of early discharge and of timely follow-up for early-discharged newborns.

DESIGN AND SETTING

Retrospective, population-based cohort study using a 1999 postpartum survey in California.

PARTICIPANTS

A total of 2828 infants of mothers with medically low-risk singleton births.

MAIN OUTCOME MEASURES

Rates of early discharge (<or=1-night stay after vaginal delivery and <or=3-night stay after cesarean section) and untimely follow-up (no home or office visit within 2 days of early discharge).

RESULTS

Overall, 49.4% of newborns were discharged early. Of these, 67.5% had untimely follow-up. The odds of early discharge were greater with lower incomes: the adjusted odds ratios (AORs) (with 95% confidence intervals) were 2.06 (1.50-2.83) for incomes <or=100% of poverty, 2.20 (1.65-2.93) for incomes from 101%-200% of poverty, and 2.24 (1.63-3.08) for incomes from 201%-300% of poverty. Untimely follow-up was more likely for infants of women with incomes <or=100% of poverty (AOR = 1.89 [1.13-3.17]) and 201%-300% of poverty (AOR = 1.78 [1.09-2.91]), Medicaid coverage (AOR = 1.73 [1.20-2.47]), Latina ethnicity (AOR = 1.47 [1.02-2.14]), and non-English language (AOR = 1.72 [1.16-2.55]).

CONCLUSIONS

Despite an apparent decline in short stays after legislation, many newborns--particularly from lower-income families--continue to be discharged early. Most newborns discharged early--particularly those with Medicaid and those from low-income, Latina, and non-English-speaking homes--do not receive recommended follow-up. The most socioeconomically vulnerable newborns are receiving fewer postnatal services.

Parents' labour market participation as a predictor of children's health and wellbeing: a comparative study in five Nordic countries

OBJECTIVE

To study the association between parents' labour market participation and children's health and wellbeing.

DESIGN

Parent reported data on health and wellbeing among their children from the survey Health and welfare among children and adolescents in the Nordic countries, 1996. A cross sectional study of random samples of children and their families in five Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden).

PARTICIPANTS

A total of 10 317 children aged 2-17 years.

RESULTS

Children in families with no parents employed in the past six months had higher prevalence of recurrent psychosomatic symptoms (odds ratio 1.67, 95% confidence intervals 1.16 to 2.40), chronic illness (odds ratio 1.35, 95% confidence intervals 1.00 to 1.84), and low wellbeing (odds ratio 1.47, 95% confidence intervals 1.12 to 1.94). Social class, family type, parents' immigrant status, gender and age of the child, respondent, and country were included as confounders. When social class, family type and the parents' immigrant status (one or more born in the Nordic country versus both born elsewhere) were introduced into the model, the odds ratios were reduced but were still statistically significant. Health outcomes and parents' labour market participation were associated in all five countries.

CONCLUSIONS

Children in families with no parents employed in the past six months had higher prevalence of ill health and low wellbeing in the five Nordic countries despite differences in employment rates and social benefits.

Changes in use of health insurance and food assistance programs in medically underserved communities in the era of welfare reform: an urban study

OBJECTIVES

The purpose of this study was to assess changes in health insurance and food assistance enrollment following passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.

METHODS

Extant data sources were used to calculate changes in Temporary Assistance for Needy Families (TANF), Medicaid, and Food Stamp program enrollment in medically underserved Manhattan communities after 1996.

RESULTS

Dramatic declines in TANF enrollment were accompanied by declines in Food Stamp program enrollment and a deceleration in Medicaid enrollment among several communities.

CONCLUSIONS

As the Personal Responsibility and Work Opportunity Reconciliation Act comes up for reauthorization later in 2002, policymakers should revise legislation so that needy families do not lose health insurance or food assistance support.

Mental health services for youths in foster care and disabled youths

OBJECTIVES

This study assessed whether mental health services for youths differ with respect to medical assistance aid category.

METHODS

Computerized claims for 15,507 youths with Medicaid insurance in a populous county of a mid-Atlantic state were used to establish population-based prevalence estimates of mental disorders and psychotherapeutic treatments during 1996.

RESULTS

An analysis of service claims revealed that the prevalence of mental disorders among youths enrolled in foster care (57%) was twice that of youths receiving Supplemental Security Income (SSI; 26%) and nearly 15 times that of other youths receiving other types of aid (4%). Rates of mental health service use were pronounced among foster care youths aged 6 to 14 years. Attention deficit/hyperactivity disorder, depression, and developmental disorders were the most prevalent disorders. Stimulants, antidepressants, and anticonvulsants were the most prevalent medications.

CONCLUSIONS

Youths enrolled in foster care and youths receiving SSI use far more mental health services than do youths in other aid categories. Additional research should evaluate the complexity and outcomes of mental health services for youths in foster care.

Vaccination status of children in the Women, Infants, and Children (WIC) Program: are we doing enough to improve coverage?

BACKGROUND

Vaccination-promoting strategies in the Supplemental Nutrition Program for Women, Infants, and Children (WIC) have been shown to produce dramatic improvements in coverage and other health outcomes.

OBJECTIVES

To determine national and state-specific population-based vaccine coverage rates among preschool children who participate in the WIC program, and to describe the strategies for promoting vaccination in WIC.

DESIGN/METHODS

Demographic data, WIC participation, and vaccination histories for children aged 24 to 35 months in 1999 were collected from parents through the National Immunization Survey. The healthcare providers for the children in the survey were contacted to verify and complete vaccination information. We defined children as up-to-date (UTD) if they had received four doses of diphtheria and tetanus toxoids and pertussis vaccine (DPT), three doses of poliovirus vaccine, one dose of measles-mumps-rubella vaccine (MMR), and three doses of Haemophilus influenzae type b vaccine (Hib) by 24 months. Description of state-level vaccination-promoting activities in WIC was collected through an annual survey completed by the state WIC and immunization program directors.

RESULTS

Complete data were collected on 15,766 children, of whom 7783 (49%) participated in WIC sometime in their lives. Nationally, children who had ever participated in WIC were less well-immunized at 24 months compared to children who had not: 72.9% UTD (95% CI, 71.3-74.5) versus 80.8% UTD (95% CI, 79.5-82.1), respectively. In 42 states, 24-month coverage among WIC participants was less than among non-WIC participants, including 13 states where the difference was > or = 10%. Vaccination activities linked with WIC were reported from 76% of 8287 WIC sites nationwide. States conducting more-frequent interventions and reaching a higher proportion of WIC participants had 40% higher vaccination coverage levels for the WIC participants in that state (p<0.05).

CONCLUSIONS

Children served by WIC remain less well-immunized than the nation's more-affluent children who do not participate in WIC. Thus, WIC remains a good place to target these children. This study provides evidence that fully implemented WIC linkage works to improve vaccination rates. Strategies that have been shown to improve the vaccination coverage levels of WIC participants should be expanded and adequately funded to protect these children.

An examination of state Medicaid financing arrangements for early childhood development services

OBJECTIVE

To determine the extent to which Medicaid finances early childhood development services, either on a capitated or fee-for-service basis, and to gauge future interest in financing such services.

METHODS

We analyzed state Medicaid managed care contracts in effect in April 1998 in 45 states using capitated arrangements for children at the end of 1997 to ascertain whether state Medicaid agencies financed any of six types of early childhood development services, including parent counseling, home visiting, comprehensive assessments, telephone advice lines, parent education classes, and case management. We also conducted structured telephone surveys with the same 45 states' Medicaid managed care directors.

RESULTS

Overall, state Medicaid agencies finance few early childhood development services on a capitated or fee-for-service basis. Case management was the most popular service to be paid for fee-for-service. Parent education was the most popular service required in managed care contracts. Parent counseling and telephone advice lines for information on child development or parenting issues were the services least likely to be reimbursed through either Medicaid financing mechanism.

CONCLUSION

To date, Medicaid agencies generally have not required managed care plans to cover early childhood development services, nor have they paid for such services on a fee-for-service basis. However, 17 states expressed an interest in expanding early childhood development services, particularly home visiting, parent education, and telephone advice lines. Nonetheless, several challenges exist in expanding Medicaid financing, including the need for more evidence on cost-effectiveness and greater political support for promoting early childhood development.

Did recent expansions in Medicaid narrow socioeconomic differences in hospitalization rates of infants?

OBJECTIVE

To test whether socioeconomic differences in the ratio of infant hospitalizations to births, a proxy for infant hospitalization rates, and hospital lengths of stay for infants narrowed between 1988 and 1992: a period of large increases in the numbers of low-income infants enrolled in Medicaid.

RESEARCH DESIGN

Before and after comparison of socioeconomic differences in the ratio of infant hospitalizations to births (ie, infant hospitalization rates) and lengths of stay between 1988 and 1992. By use of ICD-9 codes, hospitalizations were categorized as mandatory or discretionary. The difference between the 2 is that discretionary hospitalizations are potentially avoidable with appropriate primary care. Difference-in-differences techniques were used to assess the differential change in the rates of hospitalizations and lengths of stay for infants from low-income, compared with high-income, zip codes.

SETTING AND PARTICIPANTS

Discharges of infants <2 years of age at 326 nonfederal, short-term, general, and other specialty hospitals in 8 states.

OUTCOME MEASURES

Ratios of discretionary and mandatory hospitalizations to births (ie, hospitalization rates) and hospital lengths of stay of infants <2 years of age.

RESULTS

Infants from the poorest zip codes had ratios of discretionary hospitalizations to births (discretionary hospitalization rate) that were 3.1% points higher than infants from the wealthiest zip codes and ratios of mandatory hospitalizations to births (mandatory hospitalization rates) that were 0.2% points higher. Poor versus nonpoor differences in lengths of stay were 0.3 and 1.9 days for discretionary and mandatory hospitalizations, respectively. No narrowing in the socioeconomic gradients about ratios of hospitalizations to births (ie, rates of hospitalization) or lengths of stay was observed.

CONCLUSIONS

Expansions in the Medicaid program from 1988 to 1992 did not result in a decrease in ratios of discretionary hospitalizations to births (ie, discretionary hospitalization rate) or hospital length of stay for infants from low-income areas.

Developing a measure of unmet health care needs for a pediatric population

BACKGROUND

Quantified measures of unmet health care needs can be used to evaluate health care interventions, assess the impact of managed care, monitor health status trends in populations, or assess equity of access to medical care across population subgroups. Such a measure needs to be simple, relatively easy to obtain, inexpensive, and appropriately targeted to the population of interest.

OBJECTIVE

To develop a measure of unmet health care needs that is specifically targeted to a pediatric population.

SUBJECTS

Study participants consisted of children, aged 1 to 5 years (n = 1,031), and adolescent mothers, aged 13 to 19 years (n = 172), predominantly from poor, minority families in New York City.

RESEARCH DESIGN

Based on a measure, the symptoms-response ratio, developed for all age groups, this study replicated Taylor's procedures specifically for children and adolescents. Respondents were asked if they had experienced a set of physical symptoms and if they saw a doctor in response. A panel of pediatricians rated the same symptoms as to whether health care should be sought.

RESULTS

The measure achieved adequate inter-rater reliability and good construct validity. The children's overall use of health services did not differ from the pediatric panel's expectations, but with differing degrees of unmet needs by symptom. Adolescents sought care less often than the expert panel members believed they should.

CONCLUSIONS

The symptoms-response ratio provides a good balance of a simple and inexpensive measure while yielding a fair estimate of unmet needs for primary care. This analysis created a pediatric measure targeted to the needs of young children and adolescent females.

Immunization registries in the United States: implications for the practice of public health in a changing health care system

Although immunization rates among children are rising across the country, rates in inner-city areas have remained at approximately 50%-60%, < or = 30% lower than corresponding suburban or state immunization levels. The failure to raise immunization levels in poor, underserved populations is caused in part by the lack of timely and accurate child-specific immunization information for providers and parents. Immunization registries are a new tool in health care that can be used to address these and other barriers to effective immunization delivery. Moreover, immunization registries have the potential to help health care officials track and improve delivery for a broad range of important child health services. An immunization registry is a computerized database of information on children (usually preschool-age children) in a defined population (e.g. those enrolled in a health maintenance organization or living in a specific geographic area), which is used to record and track all immunizations received by each child. The registry receives the information primarily from public and private providers that administer immunizations, as well as from parents, schools, and other agencies. A fully functioning immunization registry can be used to identify individual children in need of immunizations and to report on immunization rates by population characteristics such as child age, assigned provider, or geographic area (e.g. neighborhood, city). Today, > 250 local public health departments have immunization registries that are in various stages of planning or development. Only a small number of these registries meet the minimum functional criteria of maintaining records on 95% of all eligible 2-year-old children in the target population and providing an electronic immunization record that is accessible to providers. Nascent immunization registries represent innovative technologic solutions to the challenge of monitoring health problems and health care access on a population basis. This is a fundamental activity of public health agencies, but one that is increasingly shared by large health maintenance organizations. The study of the development of immunization registries across the United States provides an important case study for how public health agencies will use the rapidly developing health information infrastructure to perform health assessment and health assurance activities in a managed care environment.

Health care utilization by children with chronic illnesses: a comparison of medicaid and employer-insured managed care

OBJECTIVES

This study compared utilization of health care services by children with chronic conditions who were insured by either Medicaid or an employer group in 1992 and 1993. Five chronic conditions were selected to illustrate patterns of service use: asthma, attention deficit disorder, diabetes, epilepsy, and sickle cell anemia.

METHODOLOGY

Administrative databases were used to develop estimates of health services utilization for children <18 years of age with the five selected conditions, who had been enrolled for at least 6 continuous months. All claims for a child identified with one of these five conditions were included in the analysis, including claims for diagnoses and procedures not directly related to the primary diagnosis. Estimates were derived for eight services (eg, hospital admissions, emergency department (ED), home health). Data were used from two Independent Practice Association model health plans in two states. Differences across the states were controlled by selecting one Medicaid and one employer-insured program from each of the two plans in both states. Regional variation was controlled for because both health plans were located in one geographical region. In each case, physicians were paid on a fee-for-service basis, with generally open access to specialists rather than primary care gatekeeper models of delivery: t tests were used to compare service use rates between Medicaid and employer-insured populations.

RESULTS

A total of 8668 children across all health plan groups had at least one of the selected conditions. Because Medicaid enrolled-children tended to be younger, analyses were adjusted for age. In both systems, a greater percentage of Medicaid children had these five study conditions (5%) compared with employer-insured children (3%), suggesting that the Medicaid population was sicker. Mean length of enrollment during the 2-year study was longer for children in employer-insured programs. Children with chronic conditions enrolled in Medicaid managed care generally used services at a higher rate compared with children with similar conditions enrolled in employer-insured managed care. The extent of the increased use varied by condition, by service type, and by plan. Children with any of the chronic conditions studied had from 2 to almost 5 times more ED visits if they were enrolled in Medicaid than if they were enrolled in employer-based managed care, depending on the specific condition. In one of the two plans, Medicaid-enrolled children had more outpatient services, laboratory services, and radiography services than their counterparts in employer-based managed care. The same pattern of use was found for home health services (except for children with diabetes) and for office visits (except for children with sickle cell). The results show higher use of all services by children with asthma and diabetes in Medicaid managed care compared with employer-based managed care. In contrast, the pattern is mixed for children with epilepsy and sickle cell. The sample size of children with these conditions was smaller than with the three other conditions, which may account, in part, for a varied pattern of results. The pattern of use for attention deficit hyperactivity disorder (ADHD) was generally different from the other conditions. Children with ADHD in employer-based managed care had more hospital admissions, hospital days, and office visits than their counterparts in Medicaid managed care. In contrast, Medicaid-enrolled children with ADHD had more ED visits, laboratory services, outpatient hospital visits, and radiography services. Other than ED visits, the differences in service use between Medicaid and employer-insured children with ADHD were minimal. Of note, the pattern for ADHD is the same for most services for Plans A and B (excluding home health visits). This utilization pattern may reflect service use for comorbid conditions. Part of this difference may be explained by differences in Medicaid e

Developmental screening scores among preschool-aged children: the roles of poverty and child health

OBJECTIVES

To investigate, using a nationally representative sample of preschool-aged children, the relationship among poverty history, child health, and risk of an abnormal developmental screening score.

METHODS

Data were derived from the 1988 National Maternal and Infant Health Survey and 1991 Longitudinal Follow-up. Family income in the child's prenatal year and at 2 years old defined a poverty history for each child. Multivariate logistic regression was used to estimate the effects of poverty history on risk of an abnormal screening score or delays in large-motor, personal-social, or language subscales.

RESULTS

Poor and near-poor children were 1.6 to 2.0 times as likely as nonpoor children to be classified as abnormal, even when maternal and household characteristics and the child's health history were taken into account. Preterm birth, chronic illness, dearth of reading materials in the home, and maternal depression were also associated with elevated risks of abnormal scores.

CONCLUSIONS

Poverty is the largest single predictor of an abnormal developmental screening score. The implications of inadequate medical care among poor children for the interpretation of individual screening scores and for amelioration of problems are also discussed.

Infant development and developmental risk: a review of the past 10 years

OBJECTIVE

To review critically the research on infant developmental risk published in the past 10 years.

METHOD

A brief framework on development in the first 3 years is provided. This is followed by a review of pertinent studies of developmental risk, chosen to illustrate major risk conditions and the protective factors known to affect infant development. Illustrative risk conditions include prematurity and serious medical illness and infant temperament, infant-caregiver attachment, parental psychopathology, marital quality and interactions, poverty and social class, adolescent parenthood, and family violence.

RESULTS

Risk and protective factors interact complexly. There are few examples of specific or linear links between risk conditions and outcomes during or beyond the first 3 years of life. Infant development is best appreciated within the context of caregiving relationships, which mediate the effects of both intrinsic and extrinsic risk conditions.

CONCLUSIONS

Complex and evolving interrelationships among risk factors are beginning to be elucidated. Linear models of cause and effect are of little use in understanding the development of psychopathology. Refining our markers of risk and demonstrating effective preventive interventions are the next important challenges.

The effects of poverty on child health and development

Poverty has been shown to negatively influence child health and development along a number of dimensions. For example, poverty-net of a variety of potentially confounding factors-is associated with increased neonatal and postneonatal mortality rates, greater risk of injuries resulting from accidents or physical abuse/neglect, higher risk for asthma, and lower developmental scores in a range of tests at multiple ages. Despite the extensive literature available that addresses the relationship between poverty and child health and development, as yet there is no consensus on how poverty should be operationalized to reflect its dynamic nature. Perhaps more important is the lack of agreement on the set of controls that should be included in the modeling of this relationship in order to determine the "true" or net effect of poverty, independent of its cofactors. In this paper, we suggest a general model that should be adhered to when investigating the effects of poverty on children. We propose a standard set of controls and various measures of poverty that should be incorporated in any study, when possible.

Injury prevention awareness in an urban Native American population

The injury-related mortality rate for Native American children between the ages of 1 and 4 years is nearly three times that of the same age group in the general population. To assess injury prevention awareness in urban Native American families, we administered 39 age-appropriate questions from the Framingham Safety Survey to 50 Native American families and 100 other families and developed an answer scoring system to analyze and compare survey responses. Survey responses revealed that Native American families are less likely to keep small objects, household products, and medicines out of the reach of their children and to possess and understand the use of ipecac. Although urban Native-American families appear to be less aware of ingestion prevention practices than other urban families, these and other deficiencies in injury prevention awareness are more likely the result of factors related to their low-income status than to culturally based practices.

Pediatric HIV disease. The newest chronic illness of childhood

HIV disease has emerged as a major chronic illness of childhood. Children with HIV infection and children with other chronic health impairments have much in common, including the need for comprehensive, multidisciplinary, coordinated care that includes special attention to the psychosocial effects on the child and family. However, because the mother and often the father and siblings share this lethal viral infection, the impact of HIV disease upon the family surpasses that of virtually all other chronic conditions. This is compounded by the association of the disease with drug use, its preponderance among the most disenfranchised populations in the United States, and the persistent public fear and discrimination surrounding AIDS. We have made substantial progress already in the medical management of this infection, and while we await the development of more effective therapies, we already have the tools and knowledge in hand to help these families.