The impact of social stressors and social networks on pediatric medical care use

A prospective study on the association between social support perceived by parents of children aged 1-7 years and the use of community youth health care services

Aim

This study examined the association between social support perceived by parents of children aged 1-7 years and the use of additional community youth health care services.

Methods

Data of 749 parents of children aged 1-7 years, gathered in the CIKEO cohort study in the Netherlands, were analyzed. Social support was assessed with the Multidimensional Scale of Perceived Social Support. Data on the use of additional community youth health care services during a period of 1.5 years were obtained from the electronic records of participating youth health care organizations. Multivariable logistic regression models were used to examine the association between perceived social support and the use of additional youth health care services and to explore moderation by the parent's educational level.

Results

The mean age of the responding parents was 33.9 years (SD = 5.1); 93.6% were mothers. Parents who perceived low to moderate levels of social support had 1.72 (95% CI: 1.11, 2.66) times higher odds of using one or more additional youth health care services during the study period compared to parents who perceived high levels of social support at baseline. This association was independent of predisposing factors, but not independent of need factors (p > 0.05). Furthermore, the association was moderated by the educational level of the parent (p = 0.015). Among parents with a high educational level, low to moderate levels of perceived social support at baseline were associated with 2.93 (95% CI: 1.47, 5.83) times higher odds of using one or more additional youth health care services during the study period independent of predisposing and need factors. Among parents with a low or middle educational level the association between perceived social support and use of additional youth health care services was not significant.

Conclusion

Our findings provide evidence that low to moderate levels of perceived social support are associated with a higher use of additional community youth health care services among parents of children aged 1-7 years, especially among high educated parents. Recommendations for policy and practice are provided.

Health Care Access and Utilization for Latino Youth in the United States: The Roles of Maternal Citizenship and Distress

OBJECTIVES

We sought to determine the associations between maternal citizenship and health care access and utilization for US-born Latino youth and to determine whether maternal distress is a moderator of the associations.

METHODS

Using 2010-2017 Integrated Public Use Microdata Series National Health Interview Survey data, multivariable logistic regressions were run to examine the associations among maternal citizenship and health care access and utilization for US-born Latino youth. Maternal citizenship and distress interactions were tested.

RESULTS

Noncitizen mothers had higher odds of reporting uninsurance, lack of transportation for delaying care, and lower odds of health care utilization for their youth than citizen mothers. Compared with no distress, moderate and severe distress were positively associated with uninsurance, delayed medical care due to cost, lack of transportation, and having had an emergency department visit for their youth. Moderate distress was positively associated with youth having had a doctor's office visit. Noncitizen mothers with moderate distress were less likely to report their youth having had an emergency department visit than citizen mothers with moderate distress. Among severely distressed mothers, noncitizen mothers were more likely to report youth uninsurance and delayed care due to lack of transportation compared with citizen mothers.

CONCLUSIONS

Health care access and utilization among US-born Latino youth are influenced by maternal citizenship and distress. Maternal distress moderates the associations among maternal citizenship and youth's health care access and use. Almost one-third of all US-born youth in the United States are Latino and current federal and state noninclusive immigration policies and anti-Latino immigrant rhetoric may exacerbate health care disparities.

Implications of Mothers' Social Networks for Risky Infant Sleep Practices

OBJECTIVE

To describe the structure of networks in a cohort of mothers and to analyze associations of social network characteristics and norms with infant sleep practices.

STUDY DESIGN

We recruited a prospective cohort of mothers with infants <6 months of age from January 2015 to December 2016. Mothers completed a survey about their personal social networks and infant care practices. Latent class analysis identified unobserved network types. Binary statistics and path analysis were performed.

RESULTS

Overall, 402 mothers were surveyed. Latent class analysis identified 2 a priori unknown social network types: "exclusive" (restricted) and "expansive." Mothers who were black, younger, unmarried, less educated, and of lower socioeconomic status were more likely to have exclusive networks than expansive networks. Mothers with exclusive networks were more likely to be exposed to the norm of soft bedding (P = .002). Exposure to norms of non-supine infant placement, bedsharing, and soft bedding use within one's network was associated with engaging in these practices (P < .0001 for each). First-time mothers were more likely to pay attention to a non-supine norm and place infants in a non-supine position. Black mothers and first-time mothers were more likely to pay attention to the norm and use soft bedding.

CONCLUSIONS

Both the type of networks mothers have and the norms regarding infant sleep practices that circulate within these networks differed by race. Network norms were strongly associated with infant sleep practices and may partially explain the racial disparity therein.

Impact of social support on oral health among immigrants and ethnic minorities: A systematic review

Objective

Adaptation to social life changes after migration may be beneficial or detrimental to migrants’ oral health outcomes and related behaviors. This systematic review aims to synthesize the scientific literature on the impact of social support on immigrants’ and ethnic minorities’ oral health status and/or behaviors.

Methods

A comprehensive electronic search, up to November 2018, was conducted using five electronic databases. We included cross-sectional and longitudinal quantitative studies that examine associations between social support and oral health outcomes among immigrants and ethnic minorities. Study selection, data extraction, and risk of bias assessment were completed in duplicate and the Newcastle-Ottawa checklist was used to appraise the methodological quality of the quantitative studies.

Results

A total of 26 studies met the eligibility criteria. Included studies examined multiple oral health outcomes such as dental care utilization, oral health behaviors, oral health problems, self-rated oral health, oral health knowledge, and oral health-related quality of life among immigrants and ethnic minorities. The social support level is assessed either by social support indicators or by adapting certain scales. Overall, social support was found to be positively associated with dental care utilization, number of carious teeth, periodontal disease, oral health behaviors, oral health knowledge, oral health-related quality of life, and self-rated oral health.

Conclusion

Although immigrants and ethnic minorities encounter several challenges after migration to a new country that could affect their oral health, social support from their surrounding environment in the form of structural or functional support plays an important role in improving their oral health outcomes.

Parents' depression and loneliness during pregnancy and respiratory infections in the offspring: A prospective birth cohort study

Background

An association between maternal prenatal stress and increased rates of respiratory tract infections in the offspring has been described earlier. Data regarding the father’s role is lacking. In this study our aim was to evaluate, whether mothers’ and fathers’ depressive symptoms and loneliness during pregnancy predict higher rates of respiratory tract infections in the offspring.

Methods

In this longitudinal cohort study we gathered information on parental psychological risk during gestational week 20 using the BDI-II and UCLA loneliness scale questionnaires for the parents of 929 children. Loneliness was divided into social and emotional components, the former describing patterns of social isolation and the latter a perceived lack of intimate attachments. Episodes of acute otitis media, physician visits due to respiratory tract infections, and antibiotic consumption relating to respiratory tract infections were documented in the infants, excluding twins, from birth until 10 months of age using study diaries. Analyses were carried out by structural equation modeling, which provides dynamic estimates of covariances.

Results

Maternal depressive symptoms during pregnancy predicted higher rates of acute otitis media in the infant and maternal emotional loneliness predicted higher rates of physician visits. Acute otitis media, physician visits and antibiotic consumption in the infant were slightly less frequent for families who reported social loneliness in the father or mother. Associations remained when taking into account confounders.

Conclusions

Maternal prenatal depression and emotional loneliness predicted a higher burden of respiratory tract infections in the offspring. The protective influence of parental social loneliness on the burden of respiratory tract infections in infants was not in line with our study hypothesis, but could be explained by reduced use of healthcare services in these socially isolated families.

The role of parental health care utilization in children's unnecessary utilization in China: evidence from Shaanxi province

Background

China has a large population of children under 18 years of age, whose health is of great concern to the Chinese health care system. However, few studies have been conducted to analyze the factors associated with children’s unnecessary health care utilization in China. The objective of this study is to provide some empirical evidence on this issue by investigating the role of parental health care utilization in children’s unnecessary health care use.

Methods

The data were obtained from the fifth Health Service Survey of Shaanxi province in 2013. We employed three dependent variables to measure children’s health care utilization: the number of children’s outpatient visits during the past 2 weeks, whether or not infusion was used if the child had any outpatient visits during the past 2 weeks, and the number of children’s inpatient visits during last year. Based on specific characteristics of these outcome variables, negative binomial models were used for the non-negative numbers of outpatient and inpatient visits, while a probit model was used for the zero-one indicator variable showing whether infusion was used during outpatient visits.

Results

Based on a sample of 11,024 children, our results of multivariate analysis showed that children whose parents used outpatient care were estimated to have a larger number of outpatient visits than those whose parents did not have outpatient visits in the past 2 weeks (with a difference of 0.0393 visits). Among children having outpatient visits in the last 2 weeks, the probability of obtaining infusion was 57.01 percentage points higher for children whose parents used infusion in the past 2 weeks than the probability for those whose parents did not use infusion. The predicted number of inpatient visits was higher for children whose parents used inpatient services in the last year, compared with the group whose parents did not use (with a difference of 0.0567 visits). Moreover, we noted that the positive association between parental and children’s health care use was more prominent among younger children.

Conclusions

Chinese children whose parents were high health care users were more likely to overuse health care services, holding other factors constant. Parents can play an important role in reducing children’s unnecessary outpatient visits, infusion use, and inpatient visits. The results suggest that interventions aimed at affecting patterns of parental use may be helpful in improving appropriate health care utilization for children.

Kin and birth order effects on male child mortality: three East Asian populations, 1716-1945

Human child survival depends on adult investment, typically from parents. However, in spite of recent research advances on kin influence and birth order effects on human infant and child mortality, studies that directly examine the interaction of kin context and birth order on sibling differences in child mortality are still rare. Our study supplements this literature with new findings from large-scale individual-level panel data for three East Asian historical populations from northeast China (1789-1909), northeast Japan (1716-1870), and north Taiwan (1906-1945), where preference for sons and first-borns is common. We examine and compare male child mortality risks by presence/absence of co-resident parents, grandparents, and other kin, as well as their interaction effects with birth order. We apply discrete-time event-history analysis on over 172,000 observations of 69,125 boys aged 1-9 years old. We find that in all three populations, while the presence of parents is important for child survival, it is more beneficial to first/early-borns than to later-borns. Effects of other co-resident kin are however null or inconsistent between populations. Our findings underscore the importance of birth order in understanding how differential parental investment may produce child survival differentials between siblings.

Correlates of Social Function: A Comparison of a Black and a White Sample of Older Persons in Los Angeles

This study compares social functioning between one Black (n = 560) and one White (n = 1350) urban, community-based sample of older persons in Los Angeles. A 3-item social function scale that assessed visiting with family and friends, participating in community activities, and taking care of other people was administered; the instrument also assessed basic activities of daily living (BADL) and intermediate activities of daily living (IADL). In multivariate analysis, social function was substantially higher for Blacks than for Whites, although BADL and IADL scores were somewhat lower for Blacks. BADLs, IADLs, being male, and being married were positively associated with social function among Blacks; IADLs, owning a home, and history of falls were negatively associated with social function among Whites. The high social function of Blacks, despite more physical limitations, suggests that even physically impaired Black older persons in the South Central Los Angeles community may remain actively involved in the family and community.

Health service use and costs for infant behaviour problems and maternal stress

AIM

We aim to describe health service (HS) use in the first 6 months post-partum and to examine the associations between service costs, infant behaviour and maternal depressive symptoms.

METHODS

Participants were 781 infants and mothers in Melbourne, Australia. Mothers reported infant feeding, sleeping and crying problems, depressive symptoms and health service use. Costs were valued in 2012 Australian dollars.

RESULTS

The most common services used were maternal child health nurses, general practitioners (GP) and allied health. Infant feeding problems were associated with increased costs for services relevant to infant behaviour including maternal child health nurses (P = 0.007), GP (P = 0.008) and paediatricians (P = 0.03). Maternal depressive symptoms were associated with increased costs for services relevant to depressive symptoms including parenting centres (P = 0.04), GP (P = 0.004), psychiatrists (P = 0.02) and psychologists (P = 0.001). Mothers who completed high school had higher service costs for infant problems than those with lower education (P = 0.02). Single mothers had higher costs for services used for their depressive symptoms than partnered mothers (P < 0.001). Mothers with English as a second language had lower service costs for their depressive symptoms (P = 0.02).

CONCLUSIONS

Infant feeding problems and maternal depressive symptoms are associated with higher costs for health services relevant to these conditions. Cost-effective strategies to manage these conditions are needed with accessibility being ensured for mothers who are experiencing social adversity.

Knowledge acquisition for medical diagnosis using collective intelligence

The wisdom of the crowds (WOC) is the process of taking into account the collective opinion of a group of individuals rather than a single expert to answer a question. Based on this assumption, the use of processes based on WOC techniques to collect new biomedical knowledge represents a challenging and cutting-edge trend on biomedical knowledge acquisition. The work presented in this paper shows a new schema to collect diagnosis information in Diagnosis Decision Support Systems (DDSS) based on collective intelligence and consensus methods.

Socioeconomic analysis of patient-centric networks: effects of patients and hospitals' characteristics and network structure on hospitalization costs

Improving operations and delivery of cost-effective healthcare services is considered to be an important area of investigation due to the challenges in allocation of resources in meeting the increasing cost of health care for the twenty-first century. To date, appropriate mechanisms for systematic evaluation of hospital operations and its impact of the delivery of cost-effective healthcare services are lacking. This is, perhaps, the first study, which focuses on using large insurance claims data to develop a social network-based model for exploring the effect of patient-doctor tie strength and patient socio-demographic factors for exploring the social structure of operations and delivery of cost-effective healthcare services. We suggest that delivery of cost-effective healthcare services and operation is embedded within the social structure of hospitals. By exploring the mode of hospital operations in terms of their patient-centric care network, we are able to develop a better understanding of the operation and delivery of cost-effective healthcare services.

Nasoalveolar molding: prevalence of cleft centers offering NAM and who seeks it

INTRODUCTION

Nasoalveolar molding (NAM) is a treatment option available for early cleft care. Despite the growing debate about the efficacy of nasoalveolar molding, questions remain regarding its prevalence and the demographic characteristics of families undergoing this technique prior to traditional cleft surgery.

OBJECTIVES

To determine the number of teams currently offering nasoalveolar molding and to identify salient clinical and sociodemographic variables in infants and families who choose nasoalveolar molding compared with those who choose traditional cleft care across three well-established cleft centers.

RESULTS

Via phone surveys, 89% of the U.S. cleft teams contacted revealed that nasoalveolar molding is available at 37% of these centers. Chart reviews and phone correspondence with caregivers indicate that the average distance to the cleft center was 65.5 miles and caregiver age averaged 30.9 ± 5.7 years. Of families who chose nasoalveolar molding, 85% received total or partial insurance coverage. No difference in caregiver education, income, or distance to the clinic between treatment groups was found. On average, infants receiving nasoalveolar molding and cleft surgery had larger clefts and had more clinic visits than infants receiving traditional cleft surgery. Infants who were firstborn and those who did not have other siblings were more likely to receive nasoalveolar molding than were infants who were residing with other siblings.

CONCLUSIONS

Currently more than one-third of U.S. cleft centers offer nasoalveolar molding. Although the cleft size was larger in the nasoalveolar molding group, no treatment group differences in education, income, and distance to the clinic were found.

Healthcare utilization for pain in children and adolescents: a prospective study of laboratory and non-laboratory predictors of care-seeking

BACKGROUND

Few studies have focused on identifying predictors of medical consultation for pain in healthy children and adolescents.

OBJECTIVE

This investigation sought to identify parent and child laboratory and non-laboratory predictors of pediatric healthcare utilization for pain problems.

STUDY GROUP

Participants were 210 healthy children and adolescents (102 girls), aged 8-17 years who took part in a laboratory pain session.

METHODS

Three months after the laboratory session, participants were contacted by telephone to ascertain whether they had experienced pain and whether they had seen a healthcare professional for pain. Zero-order correlations among sociodemographic status, child laboratory pain responses, parent physical/mental health status and medical consultation for pain were conducted to identify relevant correlates of pediatric healthcare utilization; these correlates were subjected to multivariate analyses.

RESULTS

Bivariate analyses indicated that higher anticipated pain and bother for the cold pressor task, as well as poorer parent physical health status, were associated with pediatric medical consultation for pain, but only among girls. Sequential logistic regression analyses controlling for child age indicated that only parent physical health status, not the laboratory indicators, significantly predicted healthcare consultation for pain among girls. No parent or child correlates of care-seeking for pain emerged for boys.

CONCLUSION

The findings suggest that parents' perceived physical health plays a role in determining whether medical care is sought for pain complaints in healthy girls. These results suggest that interventions to assist parents in managing their own physical health problems could lead to reductions in medical consultation for girls' pain.

Unsettled infant behaviour and health service use: a cross-sectional community survey in Melbourne, Australia

AIMS

To investigate factors associated with health service use by women and their infants in Victoria, Australia.

METHODS

Cross-sectional screening survey of 875 women with 4-month-old infants attending immunisation clinics in five local government areas in Melbourne between May 2007 and August 2008. The self-report instrument assessed socio-demographic characteristics, unsettled infant behaviour, maternal mood (Edinburgh Postnatal Depression Scale) and, the outcome, health service use during the first 4 months post-partum.

RESULTS

Mothers and their infants used on average 2.8 different health services in the first 4 months post-partum (range 0-8). After adjustment for other factors, high health service use (defined as >3 different services) was more common in mothers whose infants were unsettled with persistent crying, resistance to soothing and poor sleep. A one-point increase on the unsettled infant behaviour measure was associated with an 8% (2-14%) increase in the use of >3 services, 9% (3-16%) in use of emergency departments, 7% (2-13%) in use of telephone helplines and 9% (3-14%) of parenting services. Poorer maternal mental health was also implicated with a one-point increase on the Edinburgh Postnatal Depression Scale associated with a 4% (0.4-8%) increase in the likelihood of using more than three services.

CONCLUSIONS

Unsettled infant behaviour is associated with increased use of multiple health services. The high use of emergency departments by families with unsettled infants found in this study suggests that enhancement of primary health-care capacity might be required.

Effects of parental military deployment on pediatric outpatient and well-child visit rates

OBJECTIVE

The objective of this study was to determine whether parental deployment affected the rates at which children of military parents accessed health care within the military health system.

METHODS

We linked outpatient health care claims data for military service members' children <2 years of age from fiscal year 2007 to the parental deployment history during the same period. Incidence rate ratios (IRRs) for all visits and well-child visits were determined according to parental deployment status.

RESULTS

A total of 169,986 children were identified, with 1,772,703 outpatient visits. Of those children, 32% had a parent deployed during the study period. Well-child visits constituted 27% of all outpatient visits. The unadjusted visit rates for all visits and well-child visits were 10.4 and 2.8 visits per year, respectively. Children of single parents had decreased rates of outpatient visits (IRR: 0.84 [95% confidence interval [CI]: 0.80-0.89]; P < .001) and well-child visits (IRR: 0.88 [95% CI: 0.84-0.93]; P < .001) during deployment. Children of married parents, however, had increased rates of both outpatient visits (IRR: 1.08 [95% CI: 1.03-1.09]; P < .001) and well-child visits (IRR: 1.08 [95% CI: 1.07-1.09]; P < .001) during deployment. There was interaction between parental marital status and deployment, which was most significant among parents <24 years of age and consistently decreased with increasing parental age.

CONCLUSIONS

Children of young, single, military parents are seen less frequently for acute and well-child care when their parent is deployed, whereas children of married parents are seen more frequently in the military health system.

Social capital and health care access: a systematic review

There is a growing interest in community-level characteristics such as social capital and its relationship to health care access. To assess the rigor with which this construct has been empirically applied in research on health care access, a systematic review was conducted. A total of 2,396 abstracts were reviewed, and 21 met the criteria of examining some measure of social capital and its effects on health care access. The review found a lack of congruence in how social capital was measured and interpreted and a general inconsistency in findings, which made it difficult to draw firm conclusions about the effects of social capital on health care access. Insights from the social network literature can help improve the conceptual and measurement problems. Future work should distinguish among bonding, bridging, and linking social capital and their sources and benefits, and examine whether three dimensions of social capital actually exist: cognitive, behavioral, and structural.

Maternal psychosocial predictors of pediatric health care use: Use of the common sense model of health and illness behaviors to extend beyond the usual suspects

Determinants of pediatric health care use extend beyond the health status of the child and economic and access considerations. Parental factors, particularly those associated with the mother, are critical. The common sense model of health and illness behaviors, which was developed to account for adult health care use, may constitute a framework to study the role of mothers in determining pediatric health care use. In the common sense model, the person's cognitive representations of and affective reactions to bodily states influence health care decision-making. There is a growing literature that points to the importance of maternal psychopathology (reflecting the affective component of the common sense model) and maternal parenting self-efficacy (reflecting the cognitive component of the model) as important contributors to pediatric health care use. The implications of this conceptualization for future research and clinical practice are discussed.

Correlations of siblings' and mothers' utilisation of primary and hospital health care: a record linkage study in Western Australia

A relationship between maternal and child use of general practitioners (GPs) has been shown to exist for some time, however, the reasons for this relationship are not clear and the extent to which this relationship extends to tertiary care is unknown. The aim of this study was to examine the relationships between the utilisation of health care by siblings and mothers over a 14 year period. A retrospective cohort study of 756 mothers and their 1494 children up to age 14 years was conducted in three general practices in Western Australia. Medicare claims and hospital morbidity records for 1984-1997 were linked using deterministic and probabilistic matching. Generalised Estimating Equations and correlations were used to examine the relationships between the utilisation of primary and hospital health care by family members. Significant correlations were found between hospital admissions of all participants and their GP visits, specialist visits, pathology and diagnostic imaging combined and hospital length of stay. There was a strong association between siblings' use of GPs. A child's rate of GP attendance increased with that of its mother. There was a weak but significant relationship between siblings' use of hospitals, and a child's hospital admission rate increased with that of its mother. It is concluded that there is a strong relationship between siblings' use of GPs and a weaker but still significant association between the hospital admissions of siblings. As expected, there were strong associations between mother and child visits to GPs. There was also an association between a mother's use of hospital and that of her children. This finding reduces the plausibility that the relationships found between utilisation of health care by siblings and mothers can be explained entirely by behavioural factors, and suggests the presence of intergenerational correlation of morbidity.

[Influence of maternal anxiety on the frequency of paediatric primary care visits]

AIM

To know the influence of mother's anxiety in the number of office visits made by the children al primary care paediatric setting.

DESIGN

Case control study.

SETTING

Primary care. 17th Health Area. Valencian Community. Spain.

PATIENTS

134 mothers. Overuse was defined as number of visits higher than the average of visits in all children plus one standard deviation in a certain period. 14.89% were over users. 46 mothers (35.12%) from over user children and 85 (64.88%) from non over users.

MEASURES

Anxiety scale STAI (Spielberger State-Trait Anxiety Inventory) short form. Mother's job and number of mother's children.

RESULTS

Mother's of over user's children score higher in STAI scale. Number of children or mother's job is not associated with STAI scores. In multivariate analysis anxiety is an important factor associated to over user's children.

CONCLUSIONS

Mother's anxiety is associated with over user's children in primary care paediatric setting. This is a modifiable factor to influence in the number of inappropriate office visits.

Use and persistence of pharmacotherapy for elementary school students with attention-deficit/hyperactivity disorder

OBJECTIVE

The aim of this study was to describe rates of attention-deficit/hyperactivity disorder (ADHD) medication treatment and relevant school services use during a 2-year period, and to examine independent predictors of these interventions.

METHOD

Parent and child interviews (n = 266) and follow-up 12-month telephone surveys (n = 220) were conducted among a high-risk sample, selected from a districtwide, stratified, random sample of elementary-school students screened for ADHD risk. Medication treatment status and school services use were assessed from multiple sources, and their predictors were identified by logistic regression modeling, adjusting for sociodemographic and parental characteristics, as well as clinical-need variables.

RESULTS

Approximately one third (35%) of the children received ADHD medications during a 2-year period, and of those treated at Time 2, approximately one third (36%) were no longer on medications at Time 3. Boys were more than twice as likely to receive ADHD medication as girls. Approximately one quarter (28%) of the children accessed school services and continued their use over 2 years. African-American youths were more likely to receive school services than were Caucasian children.

CONCLUSIONS

In this elementary school-district high-risk sample, care for ADHD was remarkable for underuse and attrition of medication treatment, as well as poor linkage to relevant school services. Interventions to improve ADHD care should include supports to access and sustain medication treatment, as well as link with school services, especially for girls.

Parents, infants and health care: utilization of health services in the first 12 months of life

OBJECTIVE

To describe patterns of health-service use in the first 12 months of life.

METHODS

In this prospective cohort study, 173 first-born infants and their families living in two middle socio-economic urban areas of Melbourne were enrolled consecutively when presenting for their initial maternal and child health nurse (MCHN) visit (at approximately 4 weeks of age). Families kept a daily "health diary" for the entire 12-month period, recording use of all health services for their infant, and reasons for the contact.

RESULTS

There was an 87% completion rate of diaries. The mean number of visits to any health service, including medical, hospitals, MCHN services, pharmacists, allied health services and naturopaths, was 35.7 (95% CI 34.7-36.6) during the 12 months. Of these, 31% (mean 10.9 visits) were visits to a general practitioner (GP) and 41.5% (mean 14.3 visits) were visits to the MCHN. Infants' visits to the MCHN were far more frequent in the first 6 months of life compared with the second 6 months (10.3 vs 3.6, P < 0.001). Rates of GP use were constant over the same periods (5.3 vs 5.7, P = 0.8).

CONCLUSIONS

In a universal health-care system, this high rate of health-service use equates to approximately one visit to a health service every 2 weeks in the first year of life. The majority of these visits appeared unrelated to illness. This previously undocumented data has implications for future integrated service delivery, health-professional training and policy development for this age group.

Birth order and mortality: a life-long follow-up of 14,200 boys and girls born in early 20th century Sweden

The present study examines the sex-specific patterns of mortality by birth order in four stages of the life-course, using Poisson and logistic regression analysis. The main question posed is whether there is any continuing social effect of birth order when (a) biological factors at birth, (b) other social factors at birth and (c) socio-economic circumstances in adulthood are adjusted for. The analyses are based on the Uppsala Birth Cohort Study consisting of all 14,192 boys and girls who were born alive at the Uppsala Academic Hospital in Sweden during the period 1915-9. The results showed that all-cause mortality differed according to birth order in all of the four studied age intervals when birth year, mother's age, birth weight, gestational age, diseases of mother, diseases of the infant, social class and mother's marital status at the time of childbirth were adjusted for. The general tendency was for laterborn siblings, particularly girls women, to demonstrate a higher mortality risk than firstborn children. However, in the oldest age group (55-80 years) the previously significant association between birth order and male mortality became insignificant when adult socio-economic circumstances were controlled for. This indicates that the long-term influence of childhood birth order position on mortality is partly mediated by adult social class, education and income. The concluding section of the paper notes that laterborn children, and especially girls, were a disadvantaged group in early 20th century Sweden. Thus, for the subjects in the present study, the childhood social conditions linked to birth order position seem to have had consequences for these individuals' health and survival that extend over the whole life-course.

Children's health care use: a prospective investigation of factors related to care-seeking

OBJECTIVES

To determine the best predictors of the amount of children's health care use.

RESEARCH DESIGN

Child health, psychosocial, and family status variables were collected. Families were then followed prospectively for 2 years to gather health care use data. Multivariate regression analysis was used to determine factors related to volume of child health care use.

SUBJECTS

367 mothers and children ages 5 to 11 years continuously enrolled in a staff model HMO.

MEASURES

Child health care visits obtained from a computerized database comprised the dependent variable. Independent variables were organized into a 5-component framework including: Demographic Characteristics; Family Characteristics; Child Health and Prior Health Care Use; Child Behavior and Mental Health; and Mothers' Mental Health and Health Care Use.

RESULTS

The volume of a child's past health care use was the best predictor of future health care use, with the presence of past acute recurring illnesses, child pain and mother's retrospective health care use also serving as significant predictors in the model. Analysis of a second model was conducted omitting children's past use of health care. In this model the mother's worry about child health was the best predictor of use, with child health and child and maternal psychosocial variables significantly contributing to explained variance in the model.

CONCLUSIONS

This study supports prior research indicating past use is the best predictor of future health care use. In addition, the study suggests that maternal perceptions of child health and maternal emotional functioning influence the decision-making process involved in seeking health care on behalf of children. Effective management of pediatric health care use needs to address broader needs of the child and family beyond solely the child's health, most notably maternal functioning.

Mental health in pediatric settings: distribution of disorders and factors related to service use

OBJECTIVES

To examine child psychiatric disorders in pediatric settings and identify factors associated with parents' use of pediatricians as resources concerning emotional/behavioral issues and use of mental health services.

METHOD

The sample consists of 5- to 9-year-olds (mean = 7.17 years, SD = 1.41) from a representative sample (N = 1,060) of pediatric practices. Parent interviews included assessments of psychiatric disorders with the Diagnostic Interview Schedule for Children (DISC-R), parental depression/anxiety, possible child abuse, stress, support, and the use of mental health services.

RESULTS

The prevalence of any DISC disorder was 16.8%. Parental depression/anxiety and possible child abuse were associated independently with 2- to 3-times higher rates of disorder. Many parents (55%) who reported any disorder did not report discussing behavioral/emotional concerns with their pediatrician. Factors associated with discussing behavioral/emotional issues were the presence of any disorder and financial stress. Factors related to seeing a mental health professional were discussing behavioral/emotional issues with the pediatrician, single parenthood, and stressful life events.

CONCLUSIONS

The prevalence rates of disorders in this setting suggest that pediatricians are well-placed to identify and refer children with psychiatric disorders. However, most parents do not discuss behavioral/emotional issues with their pediatrician. Methods for improving rates of identification and referral (e.g., routine screening) are considered.

Determinants of health and service use patterns in homeless and low-income housed children

OBJECTIVE

Previous studies of homeless children have described more health problems and service use than in housed children, but failed to control for potential confounding factors that may differ between these children. This observational study examines the relationship of homelessness and other determinants to health status and service use patterns in 627 homeless and low-income housed children.

METHODS

Case-control study of 293 homeless and 334 low-income housed children aged 3 months to 17 years and their mothers conducted in Worcester, Massachusetts. Information was collected about mothers' housing history, income, education, emotional distress, and victimization history. Standardized instruments were administered to assess children's health. Health service use questions were adapted from national surveys. Main outcome measures included health status, acute illness morbidity, emergency department and outpatient medical visits. Multivariable regression analyses were used to examine the association of family and environmental determinants, including homelessness, with health status and service use outcomes.

RESULTS

Mothers of homeless children were more likely to report their children as being in fair or poor health compared with their housed counterparts. Homeless children were reported to experience a higher number of acute illness symptoms, including fever, ear infection, diarrhea, and asthma. Emergency department and outpatient medical visits were higher among the homeless group. After controlling for potential explanatory factors, homeless children remained more likely to experience fair or poor health status (adjusted odds ratio [OR] = 2.83; 95% confidence interval [CI], 1.16, 4.87), and a higher frequency of outpatient (OR = 1.71; 95% CI, 1.18, 2.48) and emergency department visits (OR = 1.21; 95% CI, 0.83, 1.74). Mothers' emotional distress was independently associated with acute illness symptoms and frequent use of outpatient and emergency department settings.

CONCLUSIONS

Homelessness is an independent predictor of poor health status and high service use among children. The present findings highlight the importance of preventive interventions and efforts to increase access to primary care among homeless children.

Depression in former school-age mothers and community comparison subjects

This paper examines the lifetime prevalence and correlates of major depressive disorder in a cohort of former school-age mothers and compares the prevalence and correlates to those found in women of the same age, ethnicity, and geographical location as the school-age mothers. The sociodemographic characteristics show some striking differences. The former young mothers were less likely to be on public assistance (19% vs 42%), but were more likely to be working (78% vs. 55%), to have completed high school or college and to meet the DSM-III criteria for depression (10.7% vs. 4.9%) than the sample of community women. The only factor related to depression in the former school-age mothers was a diagnosis of drug/alcohol abuse or dependence.

Adaptive health behaviors among ethnic minorities

Race, ethnicity, and cultural attitudes and practices are among the variables that influence health behaviors, including adaptive health behaviors. The following discussions highlight the important role of social conditions in shaping health behaviors and the central role of family in promoting health across the Asian, Hispanic, Native American, and African American ethnic groups. Factors that may lead to health-damaging behaviors are also discussed. The need for additional research that identifies correlations among physiological, social, and behavioral factors and health behaviors, as well as underlying mechanisms, is called for.

Psychosocial influences on the use of health care by children

A prospective cohort study examined the influence of psychosocial factors on the use of general practitioners over a six-month period by 271 children (aged four to nine years) and their mothers. The study was conducted in 10 general practices in the metropolitan area of Perth. The influences of psychosocial factors on use, nonuse and frequency of use by the children were examined, taking into account sociodemographic and morbidity factors. Physical health status, maternal use and financial factors were directly associated with the children's use or nonuse of general practitioners, while maternal stress, a mother's attitude towards her child and the child's psychosocial morbidity were indirectly related. Physical health status, doctor-initiated consultations, maternal stress, children's ages and birth order were directly associated with the children's frequency of use of general practitioners. Depression and anxiety in the mothers, measured with standardised instruments, were not associated with use by the children nor was a mother's level of social support. The results point to the importance of family relationships and illness behaviour in the family when considering use of general practitioners and the importance of using standardised measuring instruments and multivariate designs when studying such complex behaviours as the use of health care.

Women's orientation toward help-seeking for mental disorders

Based on a sample survey of 1000 women in Accra Ghana, this study addresses a number of individual, social and cultural factors that have been found in previous research on diverse populations to be important determinants of treatment-seeking behavior. Bivariate analysis is used to identify those factors that are significantly related to orientation toward help-seeking for mental disorders (use of biomedical vs traditional services), and multivariate analysis is utilized to determine the importance of each, and the effect of causal beliefs independent of sociodemographic factors. The results show that perceived cause of mental disorders, area of residence, age, ethnicity, membership in voluntary associations and prior contact with medical facilities or personnel are the most important determinants of the orientation toward help-seeking for mental disorders. The implications for an effective mental health care delivery system in Ghana are discussed. Also, suggestions for further research are made.

The utilization of formal medical services for young children. The lack of impact of medical professionals in social networks

The objective of this study was to examine the impact of medical professionals in social networks on the use of formal medical care for young children's minor illnesses. 795 Swedish mothers, with only one child 5-15 months of age, were randomly sampled. The mothers were interviewed by telephone and complete interviews were conducted with 92% of them. Of the 795 mothers, 84% had a relative or friend and 24% had a physician or nurse within their social networks whom they could contact for advice and support when their children became ill. No associations were found between the mothers' access to advice and support from medical professionals within their social networks and the number of formal medical contacts for their young children's illnesses. Similarly, no associations were found between the mothers' access to advice and support from lay persons in their social networks and the use of medical services for their children.

Maternal employment, maternal care and pediatric visits for minor acute illnesses

The purpose of these analyses, based on a prospective follow-up of 532 children, was to describe reported use of three maternal care actions for minor illness episodes, and to determine if maternal employment, as well as other sociodemographic factors, were associated with maternal care behaviors prior to each child's first pediatric acute-care visit. Two factors were associated with greater use of maternal care prior to an illness episode: the mother not working outside the home and less satisfaction with medical care. These results are consistent with the hypothesis that employed women with child-care arrangements are more likely than are other women to seek medical care for symptoms that are minor and can be managed with family-initiated care.

Factors predicting stage of breast cancer at diagnosis in middle aged and elderly women: the role of living arrangements

We examined whether sociodemographic, health, and psychosocial factors predict stage at diagnosis in 444 women aged 55-84 with newly diagnosed, microscopically confirmed breast cancer. Stage was defined as local or advanced (regional or remote). One of the most interesting predictors of disease stage was living arrangement. The odds of being diagnosed with advanced disease were twice as great among women living with a spouse than among women living alone (95% CL = 1.16, 3.35), after adjusting for the effects of age, body mass index, income, comorbid conditions, smoking, and group membership. For those living with someone other than a spouse, the odds of advanced disease were 1.7 times greater than among those living alone (95% CL = 0.96, 3.06). Middle aged and older women who live alone may be more likely to monitor their own health and to use the health care system, and therefore have a greater chance of being diagnosed at an early stage of breast cancer.

Hospitalization of very low birth weight children at school age

OBJECTIVE

To assess whether very low birth weight (VLBW) increases the risk of hospitalization at school age.

DESIGN

Prospective, multisite cohort study.

PARTICIPANTS

Selected from a previous multisite, hospital-based trial, 611 VLBW children, and, from a prior representative sample, 724 children who weighed 1501 to 2500 gm and 533 who weighed > 2500 gm. All the children were re-contacted at 8 to 10 years of age for this study.

METHODS

Maternal interview with the use of standardized questions.

MAIN OUTCOME

Hospitalization in year before interview.

RESULTS

The VLBW children were three or four times more likely to be rehospitalized than children of normal birth weight, both in the year before the interview (7% vs 2%) and since birth (50% to 60% vs 22%). Morbidity and Medicaid coverage increased the risk of hospitalization in the year before the interview; non-white race decreased it. After control for other factors, however, lower birth weight remained a significant risk factor for hospitalization.

CONCLUSIONS

The VLBW children continue to have an increased risk of hospitalization; the risk is similar in magnitude to that seen in infancy.

Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature and recommendations for research and improved service delivery

Despite dramatic increases in use of hospital emergency rooms (ERs) since the 1950s, an estimated 85% of ER visits are made for non-life-threatening reasons. Using a modified version of the Andersen and Newman model of health care utilization, this paper reviews the research literature on ER use to examine what is known about factors that influence three stages of the help-seeking process: (1) problem recognition; (2) the decision to seek help; (3) the decision to use the ER. While predisposing factors other than race are not generally significant, enabling factors such as income, insurance coverage, having a usual source of care, and geographic proximity affect use of the ER, both alone and in interaction with race and other factors. The most common reason for non-urgent ER use was 'other care not available'. In addition to the absence of primary care, non-urgent use of the ER is linked to need factors arising from socioeconomic stress, psychiatric co-morbidities, and a lack of social support. Recommendations for future studies include examining prospectively all 3 stages of decision-making leading to ER use, and considering interactive effects among predictors. Implications for service delivery are discussed, including the need to re-structure health care delivery systems to provide greater access to primary care and provide more attention to psychosocial aspects of patient care in clinical settings.

Life events and daily hassles and uplifts as predictors of hospitalization and outpatient visitation

Increased occurrence of major life events and daily "hassles" and "uplifts" have been shown to be associated with several measures of health status and health care utilization. In order to test for such an association with hospital admission, a prospective study was designed. Navajo Indians presenting for either inpatient or outpatient health care at a U.S. Indian Health Service facility were questioned regarding the occurrence of major life events in the preceding six months and of hassles and uplifts in the preceding week. Two years later the subsequent numbers of outpatient visits and of hospital admissions were determined for each subject. An increased number of either major life events (relative risk 1.66) or daily hassles and uplifts (relative risk 1.87) was found to be associated with an increased risk of hospital admission. The effects of major and daily life events were additive on the risk of admission. In addition, hassles were predictive of subsequent outpatient utilization. While further demonstrating the influence of major and daily life occurrences on health care utilization, this study also shows their importance in an additional cultural setting.

Correlates of emergency room utilization in the first year of life

We conducted a case-control study to examine the correlates of emergency room use in the first year of life, particularly the role of parental health beliefs, among the families of inner-city children enrolled in a hospital-based primary care program. Data was collected by structured interviews and by medical record review. Emergency room users were more likely to have single mothers and to have acute, recurrent medical conditions than were non-users. Health beliefs differed between groups by maternal report of worry about the kinds of illnesses that her child acquires. Emergency room use was predicted by: maternal marital status, maternal worry and concern that illness interferes with her child's activity, acute recurrent illnesses, hospitalization. This model may be applicable to other populations in designing intervention strategies to modify emergency room utilization.

A study of the relationship between social network, perceived ill health and utilization of emergency care. A case-control study

Several studies have shown that persons who repeatedly turn to somatic emergency departments, besides having ailments also often have social and psychological problems. It has also been shown that this group of patients differs from the general population and can be considered a psycho-socially exposed group. In the present study a group of recurrent users (4 + yearly visits) was compared to a group of first-time visitors to the general emergency department of a middlesized metropolitan hospital. Both patient groups were asked to complete a questionnaire that contained 45 items, covering socio-demographic and social network variables, social and personal problems, perceived state of health and contacts with other care-giving institutions. The results showed that the first-time visitors were significantly younger than the recurrent users, and more often actively employed. Only 2 percent of the first-time visitors developed a behaviour of recurrent use of the ED. The recurrent users were well-known at the hospital, not only in the emergency department but also at the out-patient clinics and the social work department. The multiple Odds ratio showed that alcohol abuse, lack of close friend, general health problems and deteriorating health were important risk factors for recurrent ED use. It is suggested that an individual treatment plan including medical, social and societal measures could be one alternative in an attempt to more efficiently treat these patients.

Is there a religious factor in health care utilization?: A review

This paper reviews more than 30 studies of health care utilization in which the effects of religion variables are examined, an area previously unreviewed. The authors found that over three-quarters of these studies reported significant religious differences in rates of utilization. The most common operationalization of religion was religious affiliation (typically Protestant vs Catholic vs Jewish), although the effects of religious attendance and religiosity were occasionally examined. Most major areas of health care use are represented in this literature, including psychiatric care, maternal and child health services, dental care, and physician and hospital utilization. Despite the preponderance of significant findings, it is difficult to isolate any consistent trends, although low-order analyses seem to suggest that Jews are higher utilizers than non-Jews. New findings presented from a study in Appalachia were inconclusive. The authors discuss the conceptual limitations inherent in ways in which health services researchers typically investigate the effects of religion. Drawing on recent work in the epidemiology of religion, several recommendations are offered regarding the prospect of future research in this area.

The role of social support and life stress events in use of mental health services

This study examined the role of social supports and life stress events in use of mental health services. Data were derived from a 3-5 year longitudinal study of a general population of adults (ages 14 and older) enrolled in the RAND Health Insurance Experiment. The sample used in this analyses included those enrollees who participated for a full year in the second (N = 1979) and third (N = 2601) years of the experiment. Included were 4580 person-years of data. Statistical methods used probit regression models which controlled for a number of covariates including insurance plan, site, sociodemographic variables, physical and mental health. Results supported the following conclusions: (1) the more life events experienced, the more likely one is to use mental health services, (2) chronic types of life events are more important than acute events in predicting use of mental health services, (3) when defined as social contacts, social support does not predict use; however, when defined as social resources, the more support one has the less likely is one to use mental health services, and (4) neither social contacts nor social resources buffer the impact of life stress events on use of services.

Acute illnesses in young children and family response

Swedish speaking parents of 446 children, all around one year of age and living in the suburbs of Stockholm, participated in a three-week diary study. The aim was to describe the pattern of illnesses in children and the measures taken in the family and to correlate the findings with the socio-economic conditions of the family. A health complaint, most frequently running or blocked nose or a cough, was recorded for about 1/3 of the days of observation. Some form of family action was recorded on 70% of these days. Medicines were given on 39% of the complaint days and relatives, friends or a health professional were contacted on less than 10% of the days. In case of acute respiratory infection medicines were given or a health professional contacted more often if the symptom was recorded as severe. Most frequently the Child Health Centre nurse was consulted. The measures taken by the parents were judged to be rational. However, one quarter of the parents expressed uncertainty about the care of the acute infectious disorders of the child. Correlations between family response and socioeconomic factors were weak.

Assessing social support in elderly adults

We examined the relationship among stress, social support and health status in patients with symptomatic osteoarthritis. Further, we compared three approaches to measuring social support (i.e. objective measures, subjective indicators, and satisfaction). Generally, subjective, rather than objective, indicators of support were more strongly associated with satisfaction with the amount of support received. Regardless of how social support was assessed, we failed to find evidence that support buffers individuals from negative health-related consequences of exposure to stressors. Univariate analyses also demonstrated that being black, married, better educated, and having a higher income were positively associated with social support. Social support continues to be a complex concept in terms of its operational definition and identification of the mechanism by which it influences health outcomes.

An ecological study of the relationship between risk indicators for social disintegration and use of a somatic emergency department

During the last decade a number of studies have been dedicated to the relationship between social support and ill health. In this study the relationship between risk indicators for social disintegration in defined geographical areas and the utilization of a hospital somatic Emergency Department (ED) by the inhabitants of these areas was analyzed. Six socio-demographic variables were used as risk indicators for social disintegration. To measure illness behaviour a register of 57,481 ED visits, made by 34,915 individuals, to the General Adult ED at St Göran's Hospital was utilized. The proportions of immigrants, of adult unemployed and of persons moving into the areas were significantly related to the illness behaviour of seeking care at the ED. The results also showed a significant correlation between the sum of the six risk indicators and use of ED services for three of the four studied subgroups.