Service Coordination in Early Childhood Home Visiting: a Multiple-Case Study

Early childhood home visiting is a preventive service delivery strategy that aims to promote child and parent health, positive parenting, child development and school readiness, and family economic self-sufficiency. To meet families' needs, programs provide a combination of direct services, and referrals and linkages to community-based services. Service coordination is therefore a critical component of home visiting's role within the early childhood system of care. This multiple-case study describes facilitators and barriers to service coordination, as identified by home visiting program staff and families. We interviewed program managers, supervisors, home visitors, and families from four local home visiting programs in the eastern USA with diverse contextual characteristics that showed evidence of having strong coordination. Using multiple-case study methodology, we analyzed the data to understand key facilitators and barriers to service coordination for each case and identify and describe common themes across cases. Facilitators included interagency relationships and collaboration; a culture of teamwork; dedicated, well-connected staff; supervision; trusting relationships with families; and warm handoffs. Barriers to service coordination were limited availability and accessibility of local resources, perceived stigma among other service providers, and families' ambivalence toward some services. Home visiting staff and families emphasized that relationships at multiple levels are fundamental to service coordination, barriers are complex, and coordination is time- and labor-intensive. Coalitions that bring together diverse stakeholder groups at the state and local levels can provide meaningful coordination support to the early childhood services.

Moving toward precision in prenatal evidence-based home visiting to achieve good birth outcomes: assessing the alignment of local programs with their national models

BACKGROUND

Low birthweight and preterm birth rates are higher in the United States than in other developed countries and exhibit pronounced racial inequities. Home visiting is a strategy to promote equity in birth outcomes. Research points to precision home visiting as the path to equity. The purpose of this study is to describe local programs' risk reduction priorities, intended behavioral pathways, and expectations of home visitors; compare these local program features with those of their national model; and assess the strength of implementation systems to support staff in meeting job expectations.

METHODS

We surveyed local programs implementing one of four evidence-based home visiting models that aim to promote good birth outcomes: Family Spirit, Healthy Families America, Nurse-Family Partnership, and Parents as Teachers.

RESULTS

Representatives from 169 local programs completed the survey. Overall, 59% endorsed all their model's high priority risks, 16% endorsed all its required behavioral pathways, and 11% endorsed all its required techniques. Local programs went beyond their national model's explicit intentions. Overall, 91% of local programs prioritized risks beyond those of their model, 85% endorsed behavioral pathways beyond those of their model, 95% endorsed visitors' use of techniques not explicitly endorsed by their model but compatible with it, and 19% endorsed use of techniques judged incompatible by their model. Implementation system strength was positively associated with local program and model expectations.

CONCLUSIONS

Precision home visiting to achieve health equity requires shared learning of what works best for whom. This observational study showed the Precision Paradigm's usefulness for cross-model research to advance precision.

Changing the home visiting research paradigm: models' perspectives on behavioral pathways and intervention techniques to promote good birth outcomes

BACKGROUND

The US is scaling up evidence-based home visiting to promote health equity in expectant families and families with young children. Persistently small average effects for full models argue for a new research paradigm to understand what interventions within models work best, for which families, in which contexts, why, and how. Historically, the complexity and proprietary nature of most evidence-based models have been barriers to such research. To address this, stakeholders are building the Precision Paradigm, a common framework and language to define and test interventions and their mediators and moderators. This observational study used portions of an early version of the Precision Paradigm to describe models' intended behavioral pathways to good birth outcomes and their stance on home visitors' use of specific intervention technique categories to promote families' progress along intended pathways.

METHODS

Five evidence-based home visiting models participated. Model representatives independently completed three structured surveys focused on 41 potential behavioral pathways to good birth outcomes, and 23 behavior change technique categories. Survey data were used to describe and compare models' intended behavioral pathways, explicit endorsement of behavior change technique categories, expectations for home visitors' relative emphasis in using endorsed technique categories, and consistency in endorsing technique categories across intended pathways.

RESULTS

Models differed substantially in nearly all respects: their intended pathways to good birth outcomes (range 16-41); the number of technique categories they endorsed in any intended pathway (range 12-23); the mean number of technique categories they endorsed per intended pathway (range 1.5-20.0); and their consistency in endorsing technique categories across intended pathways (22%-100% consistency). Models were similar in rating nearly all behavior change technique categories as at least compatible with their model, even if not explicitly endorsed.

CONCLUSIONS

Models successfully used components of the Precision Paradigm to define and differentiate their intended behavioral pathways and their expectations for home visitors' use of specific technique categories to promote family progress on intended pathways. Use of the Precision Paradigm can accelerate innovative cross-model research to describe current models and to learn which interventions within home visiting work best for which families, in which contexts, why and how.

Does Child Likeability Mediate the Link Between Academic Competence and Depressive Symptoms in Early Elementary School?

The present study investigated the role of teacher-rated likeability as a mediator of the relation between low academic competence and depressive symptoms in elementary-aged children. Analyses focused on a sample of children at risk for child maltreatment living in Hawaii (n = 380). Structural equation modeling supported the hypothesized negative relations between academic competence in first grade and depressive symptoms in third grade controlling for correlated constructs (e.g., baseline social avoidance, parenting stress, externalizing problems, and internalizing symptoms). Teacher-rated likeability in second grade negatively mediated the effect of academic competence on depressive symptoms. Implications for understanding the role of early academic skill deficits and social judgments on risk for depressive symptoms as well as recommendations for interventions and prevention strategies are discussed.

Home Visiting: A Service Strategy to Reduce Poverty and Mitigate Its Consequences

Home visiting programs are increasingly recognized as an important part of the early childhood system of care in the United States. The objectives of this report are to review the rationale for home visiting; characterize the Federal Home Visiting Program; highlight the evidence of home visiting effectiveness, particularly for low income families; identify opportunities to promote coordination between medical homes and home visiting programs; and explain the critical role of research, evaluation, and quality improvement to strengthen home visiting effectiveness. Home visiting programs offer voluntary home-based services and other supports to meet the needs of vulnerable pregnant women and young families. Home visiting intends to address poverty in 2 ways. First, it promotes economic self-sufficiency directly by building parents' knowledge, skills, and motivation related to employment opportunities and by linking families with community services such as adult education and job training. Second, it mitigates the effects of poverty through direct service and community linkages to enhance parents' capacity for positive parenting and for their own health and family functioning. Home visiting has shown effectiveness in multiple domains, including family economic self-sufficiency, birth outcomes, maternal health, child health and development, and positive parenting practices. Authorized as part of the Affordable Care Act in 2010 and reauthorized in 2015, the Federal Home Visiting Program invests an unprecedented $1.9 billion in the form of grants to states to expand home visiting programs and support rigorous research. As part of the early childhood system of services, home visiting programs must coordinate with other community services and supports. Programs will be most effective when resources are used efficiently, duplication of services is avoided, and alignment and reinforcement of other providers' messages are achieved. The Federal Home Visiting Program has established 4 mechanisms of research, evaluation, and quality improvement to enhance home visiting implementation and effectiveness.

Understanding How Intimate Partner Violence Impacts School Age Children's Internalizing and Externalizing Problem Behaviors: A Secondary Analysis of Hawaii Healthy Start Program Evaluation Data

We examined the role of maternal depression and parenting stress in the relationship between intimate partner violence (IPV) and child internalizing and externalizing problems, and explored whether child gender modified these pathways. This secondary analysis used data from the Hawaii Healthy Start Program. Logistic regression models examined the associations between IPV in 1st grade and child internalizing and externalizing behaviors in 1st, 2nd, and 3rd grades. Mediation models used bootstrapping methodology and stratified models examined effect modification. Adjusted models with 214 mothers demonstrated associations between IPV and internalizing (adjusted odds ratios (aOR)=2.62; 95% CI 1.11, 6.21) and externalizing (aOR=4.16; 95% CI 1.55, 11.19) behaviors. The association with externalizing behaviors was mediated by maternal depression and parenting stress, while internalizing behaviors was mediated by depression only. Stratified models found the association between IPV and externalizing behaviors was significant for girls only. Our results support the importance of multicomponent maternal IPV interventions.

Maternal Relationship Insecurity and Depressive Symptoms as Moderators of Home Visiting Impacts on Child Outcomes

The purpose of this study was to determine the extent to which maternal relationship insecurity and severe depressive symptoms moderate home visiting impacts on developmental and behavioral outcomes in 2-year old children. In an experimental trial of the Healthy Families Alaska home visiting program, families (N = 249) were randomly assigned to home visiting (n = 126) or community services as usual (n = 123). Maternal severe depressive symptoms (CES-D ≥ 24) and relationship insecurity were measured using the Center for Epidemiologic Studies Depression Scale and the Attachment Style Questionnaire at baseline. Child cognitive and psychomotor development and behavior problems were measured with the Bayley Scales of Infant Development and the Child Behavior Checklist at follow-up. The results revealed that home visiting significantly impacted three outcomes- child cognitive development, internalizing behavior, and externalizing behavior. Home visiting impacts were limited to subgroups defined by maternal depressive symptoms and relationship insecurity. Home visiting improved cognitive development (B = 6.02, p < .03), and decreased internalizing behavior (B = -3.83, p = .02) and externalizing behavior problems (B = -3.74, p = .03) in children of mothers with either severe depressive symptoms or high levels of discomfort with trust at baseline, but not both. Family engagement in home visiting seems to play a role in mediating these moderating effects. These findings reflect the importance of screening for maternal relationship insecurity and depressive symptoms to distinguish family subgroups likely to benefit from home visiting from those for whom an enhanced service model might be needed.

Is depression associated with contraceptive motivations, intentions, and use among a sample of low-income Latinas?

BACKGROUND

Latinas in the United States experience high rates of unintended pregnancy and low rates of contraception use, yet reasons are not completely understood. Depression is common among pregnant and nonpregnant Latinas; its influence on contraceptive motivations, intentions, and use is understudied.

OBJECTIVES

We sought to 1) describe Latinas' contraceptive motivations, intentions, and use; 2) use structural equation modeling to test associations between depression and contraceptive self-efficacy/motivations/intentions/use; and 3) determine whether associations differ by pregnancy status.

METHODS

This cross-sectional study included Latinas ages 15 to 45 recruited from an urban Federally Qualified Health Center in Baltimore, Maryland. Structured surveys were used to collect data regarding depressive symptoms measured using the PHQ-9. All other constructs were measured with previously validated questions. Constructs included contraceptive self-efficacy, positive and negative contraceptive motivations (perceived advantages and disadvantages of using contraception), contraceptive intentions to begin or continue contraception use, and contraceptive methods currently used.

RESULTS

Among pregnant Latinas, depression was associated with negative motivations (β = 0.16; p < .05), negative motivations were associated with intentions (β = -0.22; p < .01), and contraceptive self-efficacy was associated with intentions (β = 0.43; p < .001). Among nonpregnant Latinas, contraceptive self-efficacy was associated with intentions (β = 0.78; p < .001) and intentions were associated with use (β = 0.40; p < .05).

CONCLUSIONS

Among pregnant Latinas, negative motivations intervene in the association between depression and contraceptive intentions. For nonpregnant Latinas, intentions intervene in the association between self-efficacy and contraceptive use. This study underscores the importance of depression screening during pregnancy and encourages practitioners to target contraceptive motivations to improve contraceptive use.

Association of substance use discussion by pediatric providers with the parent-provider relationship and maternal behavior change

A cross-sectional study of data from a randomized, controlled trial was conducted to determine (1) provider and parent attributes associated with discussion of maternal substance use, (2) how substance use discussion related to the parent-provider relationship, and (3) whether discussion was associated with maternal attempts at behavior change. Of the 482 mothers, 34% reported discussing all 3 substance use items (smoking, alcohol, and drug use) with their child's provider. Mothers who discussed smoking were more likely to report discussing alcohol and other drug use (P < .001). Parent-provider relationship scores, measured by a modified version of the Primary Care Assessment Survey, were positively associated with discussion of each substance (P < .001). Discussion of smoking and drug use were significantly associated with attempted behavior change. Our findings suggest that discussion of parental substance use by pediatricians is positively associated with the parent-provider relationship and may lead to behavior change.

The importance of early parenting in at-risk families and children's social-emotional adaptation to school

OBJECTIVE

The aim of this study was to determine the specific aspects of early parenting in psychosocially at-risk families most strongly related to children's social-emotional adaptation to school.

METHODS

A cohort study of families (N = 318) identified as at risk for maltreatment of their newborns was conducted. Quality of early parenting was observed in the home when the child was 1 year old. Social-emotional adaptation to school was reported by teachers in first grade. Multivariable models assessed the independent influence of early parenting variables on social-emotional adaptation.

RESULTS

Early parenting and social-emotional adaptation to school varied greatly across families. Parental warmth was associated with lower teacher ratings of shyness, concentration problems, and peer rejection. Parental lack of hostility was associated with decreased teacher ratings of concentration problems and peer rejection. Parental encouragement of developmental advance was associated with lower ratings of aggression and peer rejection. Provision of materials to promote learning and literacy was associated with lower ratings of concentration problems.

CONCLUSIONS

In this sample of families with multiple psychosocial risks for child maltreatment, specific aspects of early parenting were associated with better social-emotional adaptation to school in the first grade in theoretically predicted ways. Improving parental knowledge about positive parenting via anticipatory guidance should be a focus of well-child visits. Well-child visit-based interventions to improve the quality of early parenting, especially among at-risk families, should be studied for their impact on parenting behavior and on children's successful social-emotional adaptation to school. Primary care providers should reinforce complementary services, such as home visiting, that seek to promote positive parenting.

Reducing maternal intimate partner violence after the birth of a child: a randomized controlled trial of the Hawaii Healthy Start Home Visitation Program

OBJECTIVES

To estimate whether home visitation beginning after childbirth was associated with changes in average rates of mothers' intimate partner violence (IPV) victimization and perpetration as well as rates of specific IPV types (physical assault, verbal abuse, sexual assault, and injury) during the 3 years of program implementation and during 3 years of long-term follow-up.

DESIGN

Randomized controlled trial.

SETTING

Oahu, Hawaii.

PARTICIPANTS

Six hundred forty-three families with an infant at high risk for child maltreatment born between November 1994 and December 1995. Intervention Home visitors provided direct services and linked families to community resources. Home visits were to initially occur weekly and to continue for at least 3 years.

MAIN OUTCOME MEASURES

Women's self-reports of past-year IPV victimization and perpetration using the Conflict Tactics Scale. Blinded research staff conducted maternal interviews following the child's birth and annually when children were aged 1 to 3 years and then 7 to 9 years.

RESULTS

During program implementation, intervention mothers as compared with control mothers reported lower rates of IPV victimization (incidence rate ratio [IRR], 0.86; 95% confidence interval [CI], 0.73-1.01) and significantly lower rates of perpetration (IRR, 0.83; 95% CI, 0.72-0.96). Considering specific IPV types, intervention women reported significantly lower rates of physical assault victimization (IRR, 0.85; 95% CI, 0.71-1.00) and perpetration (IRR, 0.82; 95% CI, 0.70-0.96). During long-term follow-up, rates of overall IPV victimization and perpetration decreased, with nonsignificant between-group differences. Verbal abuse victimization rates (IRR, 1.14, 95% CI, 0.97-1.34) may have increased among intervention mothers.

CONCLUSION

Early-childhood home visitation may be a promising strategy for reducing IPV.

Motivational intervention to reduce rapid subsequent births to adolescent mothers: a community-based randomized trial

PURPOSE

One-quarter of adolescent mothers bear another child within 2 years, compounding their risk of poorer medical, educational, economic, and parenting outcomes. Most efforts to prevent rapid subsequent birth to teenagers have been unsuccessful but have seldom addressed motivational processes.

METHODS

We conducted a randomized trial to determine the effectiveness of a computer-assisted motivational intervention (CAMI) in preventing rapid subsequent birth to adolescent mothers. Pregnant teenagers (N = 235), aged 18 years and older who were at more than 24 weeks' gestation, were recruited from urban prenatal clinics serving low-income, predominantly African American communities. After completing baseline assessments, they were randomly assigned to 3 groups: (1) those in CAMI plus enhanced home visit (n = 80) received a multi-component home-based intervention (CAMI+); (2) those in CAMI-only (n = 87) received a single component home-based intervention; (3) and those in usual-care control (n = 68) received standard usual care. Teens in both intervention groups received CAMI sessions at quarterly intervals until 2 years' postpartum. Those in the CAMI+ group also received monthly home visits with parenting education and support. CAMI algorithms, based on the transtheoretical model, assessed sexual relationships and contraception-use intentions and behaviors, and readiness to engage in pregnancy prevention. Trained interventionists used CAMI risk summaries to guide motivational interviewing. Repeat birth by 24 months' postpartum was measured with birth certificates.

RESULTS

Intent-to-treat analysis indicated that the CAMI+ group compared with the usual-care control group exhibited a trend toward lower birth rates (13.8% vs 25.0%; P = .08), whereas the CAMI-only group did not (17.2% vs 25.0%; P = .32). Controlling for baseline group differences, the hazard ratio (HR) for repeat birth was significantly lower for the CAMI+ group than it was with the usual-care group (HR = 0.45; 95% CI, 0.21-0.98). We developed complier average causal effects models to produce unbiased estimates of intervention effects accounting for variable participation. Completing 2 or more CAMI sessions significantly reduced the risk of repeat birth in both groups: CAMI+ (HR = 0.40; 95% CI, 0.16-0.98) and CAMI-only (HR = 0.19; 95% CI, 0.05-0.69).

CONCLUSIONS

Receipt of 2 or more CAMI sessions, either alone or within a multicomponent home-based intervention, reduced the risk of rapid subsequent birth to adolescent mothers.

Examining maternal depression and attachment insecurity as moderators of the impacts of home visiting for at-risk mothers and infants

Home visiting programs for at-risk mothers and their infants have proliferated nationally in recent years, yet experimental studies of home visiting have yielded mixed findings. One promising strategy for explicating the effects of early home visiting is to examine moderators of program impacts. This study assessed the roles of maternal depression and attachment insecurity as moderators of the impacts of Healthy Families Alaska home visiting services for at-risk mothers and their infants. At-risk families (N = 325) were randomly assigned to home visiting or community services as usual (n = 162 and 163, respectively). Maternal depression and attachment insecurity (attachment anxiety and discomfort with trust/dependence) were measured at baseline. Maternal psychosocial and parenting outcomes were measured when children were 2 years old via maternal self-report, observation, and review of substantiated reports of child maltreatment. Maternal depression and attachment insecurity interacted in their moderation of program impacts. For several outcomes, home visiting impacts were greatest for nondepressed mothers with moderate-to-high discomfort with trust/dependence and for depressed mothers with low discomfort with trust/dependence. Implications for practice and policy are discussed.

Communication between key stakeholders within a medical home: a qualitative study

The objective of this study was to determine perceived benefits, detriments, and barriers to communication between pediatric providers and home visitors. The authors performed a cross-sectional, qualitative study consisting of 3 focus groups with paraprofessional home visitors (n=12), 6 with parents receiving home visiting (n=33), and 4 with pediatric providers whose patients received home visiting (n=19). Emerging themes were generated by an inductive analytic approach. Perceived benefits included home visitors assisting parents with communication, giving providers family information, and reinforcing providers' guidance. Detriments included parental concern of sharing confidential information and providers becoming aware of family issues for which they are unprepared to act. Barriers included parental consent, logistics of home visitor-provider communication, and providers' lack of knowledge about home visitor programs/roles. Greater coordination between home visitation programs and pediatric providers may strengthen home visiting services and reinforce advice and anticipatory guidance given by providers.

Impact of intimate partner violence on children's well-child care and medical home

OBJECTIVES

Intimate partner violence has been linked to poor child health. A continuous relationship with a primary care pediatric provider can help to detect intimate partner violence and connect families with needed services. The objectives of this study were to determine the relationship between intimate partner violence and (1) maternal report of a regular site for well-child care, (2) maternal report of a primary pediatric provider, (3) well-child visits in the first year of life, (4) up-to-date immunizations at 2 years of age, (5) maternal report of medical neglect, and (6) maternal report of the pediatric provider-caregiver relationship.

METHODS

This retrospective cohort study evaluated data from 209 at-risk families participating in the evaluation of the Healthy Families Alaska program. Research staff interviewed mothers near the time of an index child's birth and again at the child's second birthday. Medical charts were abstracted for information on well-child visits and immunizations.

RESULTS

Mothers who disclosed intimate partner violence at the initial interview (n = 62) were significantly less likely to report a regular site for well-child care or a primary pediatric provider. In multivariable models, children of mothers who disclosed intimate partner violence tended to be less likely to have the recommended 5 well-child visits within the first year of life and were significantly less likely to be fully immunized at 2 years of age. Differences in medical neglect were not statistically significant. Of mothers who reported a specific primary pediatric provider, those with intimate partner violence histories trusted this provider less and tended to rate less favorably pediatric provider-caregiver communication and the overall quality of the pediatric provider-caregiver relationship.

CONCLUSIONS

Future research should explore effective ways to link intimate partner violence-exposed children with a medical home and a primary pediatric provider and to improve relationships between pediatric providers and caregivers who face violence at home.

Home visiting for adolescent mothers: effects on parenting, maternal life course, and primary care linkage

PURPOSE

Adolescent mothers are at risk for rapidly becoming pregnant again and for depression, school dropout, and poor parenting. We evaluated the impact of a community-based home-visiting program on these outcomes and on linking the adolescents with primary care.

METHODS

Pregnant adolescents aged 12 to 18 years, predominantly with low incomes and of African American race, were recruited from urban prenatal care sites and randomly assigned to home visiting or usual care. Trained home visitors, recruited from local communities, were paired with each adolescent and provided services through the child's second birthday. They delivered a parenting curriculum, encouraged contraceptive use, connected the teen with primary care, and promoted school continuation. Research assistants collected data via structured interviews at baseline and at 1 and 2 years of follow-up using validated instruments to measure parenting (Adult-Adolescent Parenting Inventory) and depression (Center for Epidemiologic Studies Depression). School status and repeat pregnancy were self-reported. We measured program impact over time with intention-to-treat analyses using generalized estimating equations (GEE).

RESULTS

Of 122 eligible pregnant adolescents, 84 consented, completed baseline assessments, and were randomized to a home-visited group (n = 44) or a control group (n = 40). Eighty-three percent completed year 1 or year 2 follow-up assessments, or both. With GEE, controlling for baseline differences, follow-up parenting scores for home-visited teens were 5.5 points higher than those for control teens (95% confidence interval, 0.5-10.4 points; P = .03) and their adjusted odds of school continuation were 3.5 times greater (95% confidence interval, 1.1-11.8; P <.05). The program did not have any impact on repeat pregnancy, depression, or linkage with primary care.

CONCLUSIONS

This community-based home-visiting program improved adolescent mothers' parenting attitudes and school continuation, but it did not reduce their odds of repeat pregnancy or depression or achieve coordination with primary care. Coordinated care may require explicit mechanisms to promote communication between the community program and primary care.

Mild cognitive impairment in early life and mental health problems in adulthood

OBJECTIVES

We assessed the extent to which borderline mental retardation and mental retardation at preschool ages are related to emotional and behavioral problems in young adulthood. We also explored early risk factors for having mental health problems as a young adult that might be related to preschool differences in cognitive ability.

METHODS

We used data from a cohort of births studied in the Johns Hopkins Collaborative Perinatal Study and followed up in the Pathways to Adulthood Study. Preschool cognitive functioning was assessed at 4 years of age. Individual characteristics, psychosocial factors, and mental problems were prospectively evaluated from birth through young adulthood.

RESULTS

Children with subaverage cognitive abilities were more likely to develop mental health problems than their counterparts with IQs above 80. Inadequate family interactions were shown to increase 2- to 4-fold the risk of emotional or behavioral problems among children with borderline mental retardation.

CONCLUSIONS

Subaverage cognitive functioning in early life increases later risk of mental health problems. Future research may help to delineate possible impediments faced at different developmental stages and guide changes in supportive services to better address the needs of children with borderline mental retardation.

The association between intrauterine growth restriction in the full-term infant and high blood pressure at age 7 years: results from the Collaborative Perinatal Project

OBJECTIVE

To use neonatal and placental anthropometry as proxy measures of intrauterine growth restriction (IUGR) and to relate these to blood pressure later in childhood.

STUDY DESIGN

A post hoc analysis of full-term white and black children from the Collaborative Perinatal Project, followed from birth until age 7 years (n = 29,710). Blood pressure above the 90th percentile by gender and race was considered high blood pressure. Anthropometric measures at birth included birth weight, ponderal index (PI, birth weight/birth length(3)), head to chest circumference (HCC) ratio, and placental ratio percentage (PRP, placental weight(*)100/birth weight).

RESULTS

Among anthropometric measures, PI, HCC, and birth weight were not associated with high systolic blood pressure at age 7 years, but PRP was. In multiple logistic regression, high systolic blood pressure and widened pulse pressure were both predicted by increased PRP [odds ratio (OR) 1.03 and 1.04, P < 0.001] but not by birth weight, when adjusted for gender, race, and maternal education. High diastolic blood pressure was weakly predicted by birth weight (OR 1.10, P = 0.05) but not by PRP.

CONCLUSIONS

PRP is associated with an increased risk for high systolic blood pressure and pulse pressure later in childhood, whereas birth weight, PI, and HCC are not. The proportion of placental weight to birth weight is a useful marker of IUGR for studying the developmental origins of adult disease hypothesis.

Agreement of injury reporting between primary care medical record and maternal interview for children aged 0-3 years: implications for research and clinical care

OBJECTIVE

To assess agreement of injury reporting between primary care medical record and maternal interview.

METHODS

Cross-sectional study of data from a randomized controlled trial of home visiting. The setting was Hawaii's Healthy Start Program (HSP). Subjects comprised a population-based sample of children in at-risk families with 3 years of primary care medical records and maternal interviews (n = 443). Outcome measures were percentage of children injured unintentionally and mean number of injuries per child in the first 3 years of life by primary care medical record and maternal interview.

RESULTS

We identified 490 injuries: 48% by primary care medical record, 22% by maternal interview, and 30% in both sources. More children were reported injured by primary care medical record than maternal interview (51% vs 39%, P< .001). The mean number of injuries per child was 0.87 by primary care medical record and 0.51 by maternal interview (difference 0.36, 95% confidence interval 0.27-0.45, P< .001). Agreement between data sources was fair (kappa = 0.47).

CONCLUSIONS

This study estimates that 25% of childhood injuries may not be reported in the medical record, highlighting the need for reconsideration of the use of medical records as the gold standard for unintentional injury data. Caution should be used when interpreting injury data from one source, especially from families with stressful life situations. Poor communication regarding injuries between social service, primary care and urgent care providers may contribute to decreased quality of primary care and missed opportunities for injury prevention.

Formative evaluation of home visitors' role in addressing poor mental health, domestic violence, and substance abuse among low-income pregnant and parenting women

OBJECTIVES

This research assessed home visitor effectiveness in communicating about and responding to poor mental health, domestic violence, and substance abuse among pregnant and parenting women home visited as part of a comprehensive family support strategy in seven urban communities.

METHODS

Cross-sectional studies were conducted with mothers (n = 189) actively engaged in home visitation programs and home visitors (n = 45). Maternal interviews assessed need for and receipt of mental health, domestic violence, and substance abuse services, and home visitor discussion of these risk areas. Home visitor surveys assessed perceived adequacy of training and personal effectiveness in addressing these risk areas.

RESULTS

Over half of mothers needed mental health, domestic violence, or substance abuse services; however, only 27% of mothers in need of service received services. Most mothers reported having communicated with their home visitor about the three risk areas, but there were no differences in communication frequency based on whether services were needed. Most home visitors perceived themselves as effective in communicating about and responding to these risk factors but rated the training they had received in these areas as less than adequate.

CONCLUSIONS

Home visitors could benefit from more intensive training in the formal assessment of risks and the protocols for communication about those risks with their clients. Home visitors could also receive support from and work in collaboration with professionals in addressing client risks. Further research on home visit content is needed to determine which strategies facilitate home visitors' ability to effectively communicate about and address client risks.

Pediatric Patients with Sickle Cell Disease: Use of Complementary and Alternative Therapies

OBJECTIVE

Despite clinical advances, sickle cell disease (SCD) remains a difficult, chronic medical condition for many children and youth. Additional treatment strategies, including complementary and alternative medicine (CAM) therapies, would be welcome to enhance the clinical care of SCD patients. This study's objective was to identify CAM therapies that are currently used by families for children with SCD, and to investigate SCD families' interest in CAM.

PATIENTS AND METHODS

Fifty-seven (57) parents of pediatric SCD patients participated in this cross-sectional telephone survey in early 2000. A SCD Severity Scale was developed by combining the general health assessment and four measures of SCD severity (Cronbach's alpha = 0.81).

RESULTS

Fifty-four percent (54%) of the sample used CAM therapies for the SCD children. Forty-two percent (42%) used bioenergetic therapies (prayer, spiritual and energy healing), 28% used lifestyle/mind?body CAM (relaxation techniques, exercise, imagery, and diet), 12% used biochemical therapies (herbal medicines, megavitamins, and folk remedies), and 5% used biomechanical therapy (massage). CAM use for the SCD children was positively associated with the child's age, SCD Severity Scale score, respondent education, and respondent CAM use. The use of relaxation techniques was associated with greater SCD severity. Most respondents (83%) felt that CAM can be helpful.

CONCLUSIONS

The use of CAM therapies is common for children with SCD. Prayer, relaxation techniques, and spiritual healing were the most commonly reported CAM therapies. Because clinical studies have shown the benefit of spiritual and relaxation practices for SCD and this study shows that these CAM therapies are being used commonly by SCD families, future research should focus on spiritual and relaxation practices for children with SCD.

Knowledge and Beliefs About Guidelines for Exclusion of Ill Children From Child Care

BACKGROUND

The American Academy of Pediatrics published national child care illness exclusion guidelines in 1992 and 2002. To our knowledge, no published studies have examined child care providers', parents', and pediatricians' knowledge or beliefs about these guidelines.

OBJECTIVE

To compare parents', pediatricians', and center-based child care providers' (CCPs) knowledge and beliefs about exclusion guidelines.

DESIGN

Cross-sectional survey conducted in 2000 of 80 CCPs, 142 parents, and 36 pediatricians in Baltimore City. Main outcome measures included familiarity with and knowledge of exclusion guidelines and beliefs about exclusion effectiveness among these groups.

RESULTS

Response rates were 58% for parents, 59% for pediatricians, 85% for CCPs. Sixteen percent of child care providers (CCPs), 39% of parents, and 53% of pediatricians had not seen any written exclusion guidelines. Compared with national guidelines for 12 common symptoms, responses from CCPs and parents indicated overexclusion, while pediatricians indicated underexclusion. The groups scored similarly in number of correct answers on knowledge items (CCPs 63%, parents 64%, pediatricians 61%, P = .44). More CCPs and parents than pediatricians believed that exclusion effectively controlled infection spread and that sick children should be excluded because they spread disease, would be more comfortable, and recover faster at home (P < .001).

CONCLUSIONS

This survey found CCPs, parents, and pediatricians all failed to recognize how national guidelines recommended managing 4 out of 10 common conditions on average. CCPs were more likely than pediatricians to believe that exclusion was warranted to control infection or for the child's personal needs.

Prevalence and early identification of language delays among at-risk three year olds

The aims of this study were fourfold: to document the prevalence of language delays in a sample of at-risk 3 year olds; to assess the effectiveness of a home visiting program in preventing early language delays; to determine how often parents, pediatric providers, and home visitors identified early language delays; and to assess the effectiveness of a home visiting program in improving early identification of language delays. The Preschool Language Scale, Third Edition (PLS-3) was administered to 513 at-risk 3 year olds participating in a randomized trial of home visiting services. Families randomized to home visiting were expected to receive weekly to quarterly visits throughout the 3 years of this study. The content of home visits included teaching parents about child development, role-modeling parenting skills, and linking families to a medical home. Identification of delays was measured using structured parent interviews and review of primary care and home visiting records. At age 3 years, 10% of children had severe language delays, defined as scoring >or=2 SD below the national mean on the PLS-3, whereas 49% scored >or=1 SD below the national mean. No differences in prevalence were seen between children who did and did not receive home visiting. Among children with severe delays, 42% were identified by parents, 33% by pediatric providers, and 24% by home visitors. Among children with any delays, 24% were identified by parents, 25% by pediatric providers, and 17% by home visitors. No differences in rates of identification were seen between children who did and did not receive home visiting. Thus, while language delays were highly prevalent among these at-risk children, rates of identification were low, even among children with severe delays. Home visiting was not effective in either preventing language delays or improving early identification. This suggests that pediatric providers and home visiting programs need to reexamine their approaches to recognizing and intervening with early language delays.

Physical activity attitudes of African American and white adolescent girls

BACKGROUND

Understanding the attitudes of African American adolescent girls toward physical activity may help identify strategies to enable these adolescents to adopt a more physically active lifestyle that could track into adulthood.

OBJECTIVE

To identify and compare attitudes of African American adolescent girls toward physical activity with the attitudes of white adolescent girls.

METHODS

Six focus groups (N = 49) were conducted with 9th- through 12th-grade African American and white adolescent girls. Participants were recruited from community and medical settings in an urban city. Groups were audiotaped, coded, and analyzed for themes.

RESULTS

African American participants were more accepting of their body image than were the white participants as individuals, as a community, and in the media. Themes common among African American and white participants included appearance and hygiene, value of physical activity, and issues of masculinity. Physically active adolescents reported on the significance of social support in motivating their physical activity participation.

CONCLUSION

Future research on these attitudes could help inform the design of effective and culturally appropriate interventions to promote physical activity in African American and white adolescent girls.

Medical homes for at-risk children: parental reports of clinician-parent relationships, anticipatory guidance, and behavior changes

BACKGROUND

Family-centeredness, compassion, and trust are 3 attributes of the clinician-parent relationship in the medical home. Among adults, these attributes are associated with patients' adherence to clinicians' advice.

OBJECTIVES

The objectives were (1) to measure medical home attributes related to the clinician-parent relationship, (2) to measure provision of anticipatory guidance regarding injury and illness prevention, (3) to relate anticipatory guidance to parental behavior changes, and (4) to relate medical home attributes to anticipatory guidance and parental behavior changes.

METHODS

A cross-sectional study of data collected among at-risk families when children were 1 year of age, in a randomized, controlled trial of a home-visiting program to prevent child abuse and neglect, was performed. Modified subscales of the Primary Care Assessment Survey were used to measure parental ratings of clinicians' family-centeredness, compassion, and trust. Parental reports of provision of anticipatory guidance regarding injury and illness prevention topics (smoke alarms, infant walkers, car seats, hot water temperature, stair guards, sunscreen, firearm safety, and bottle propping) and behavior changes were recorded.

RESULTS

Of the 564 mothers interviewed when their children were 1 year of age, 402 (71%) had a primary care provider and had complete data for anticipatory guidance items. By definition, poverty, partner violence, poor maternal mental health, and maternal substance abuse were common in the study sample. Maternal ratings of clinicians' family-centeredness, compassion, and trust were fairly high but ranged widely and varied among population subgroups. Families reported anticipatory guidance for a mean of 4.6 +/- 2.2 topics relevant for discussion. Each medical home attribute was positively associated with parental reports of completeness of anticipatory guidance, ie, family-centeredness (beta = .026, SE = .004), compassion (beta = .019, SE = .005), and trust (beta = .016, SE = .005). Parents' perceptions of behavior changes were positively associated with trust (beta = .018, SE = .006). Analyses were adjusted for potential confounding by randomized, controlled trial group assignment, receipt of >or=5 well-child visits, and baseline attributes.

CONCLUSIONS

Among at-risk families, we found an association between parental ratings of the medical home and parental reports of the completeness of anticipatory guidance regarding selected injury and illness prevention topics. Parents' trust of the clinician was associated with parent-reported behavior changes for discussed topics.

Hawaii's healthy start home visiting program: determinants and impact of rapid repeat birth

OBJECTIVE

Healthy People 2010 calls for reductions in rapid repeat births (RRBs), defined as births occurring within 24 months after a previous birth for women of all ages, and prevention of repeat births during adolescence, regardless of the birth interval. Home visiting has been promoted as a mechanism to prevent child abuse and neglect and to improve pregnancy outcomes. This study aims to assess the impact of home visiting in preventing RRB and its malleable determinants and assesses the influence of RRB on the mother and the index child. We hypothesized that maternal desire to have a RRB, access to a family planning site, and use of birth control would be significant malleable determinants and that the effects of the program in preventing RRB would be mediated through its influence on these variables. We also hypothesized that the occurrence of RRB would result in increased stress and family dysfunction, resulting in adverse maternal and child outcomes such as severe maternal stress, maternal neglect of the index child, decreased maternal warmth toward the index child, and increased behavior problems of the index child.

METHODS

The Healthy Start Program (HSP) is a home visiting program to prevent child abuse and neglect and to promote child health and development among newborns of families identified as being at risk for child maltreatment. This study was a randomized, controlled trial of Hawaii's HSP, in which eligible families were randomly assigned to home-visited and control groups. A total of 643 families at risk for child abuse were enrolled between November 1994 and December 1995. Data to measure RRB and malleable determinants were collected through structured maternal interviews and observation of the home environment. We measured RRB through maternal self-report by asking about a subsequent birth in follow-up interviews at 1, 2, and 3 years. To measure the malleable determinants, we measured the mother's desire for a RRB at baseline and at the 1-year interview and determined whether she had access to a family planning site. The mother was also asked which contraceptive methods she had ever used in the past and which methods, if any, she used in the year following the index child's birth. We measured 3 maternal parenting outcomes at the year 3 follow-up interview, ie, parenting stress, neglectful behavior toward the index child, and warmth toward the index child. We used odds ratios with 95% confidence intervals (CIs) to measure the strength of associations. Multiple logistic regression was used to assess 1) program effects on RRB and its malleable determinants, 2) the impact of the malleable determinants on RRB, and 3) the association between RRB and adverse maternal and child outcomes.

RESULTS

Each year, 88% of the sample completed a follow-up interview; 81% completed all 3 follow-up interviews. There was no program impact on RRB for mothers overall (HSP: 21%; control: 20%; adjusted odds ratio [AOR]: 1.05; 95% CI: 0.69-1.58). HSP and control groups did not differ significantly in any of the malleable determinants of RRB. When we combined the 2 study groups, malleable determinants had significant effects on RRB. Mothers with a desire to have a child within 2 years after the index birth were significantly more likely to have a RRB, whether this desire was expressed at baseline (AOR: 2.48; 95% CI: 1.32-4.64) or at the year 1 interview (AOR: 2.86; 95% CI: 1.57-5.22). Lack of access to a family planning site at baseline was not associated with RRB, but there was a trend toward a greater likelihood of RRB among those lacking a site at 1 year (AOR: 1.61; 95% CI: 0.93-2.79). Women who had never used birth control before the index birth were more likely to have a RRB (AOR: 1.89; 95% CI: 1.20-2.98), and there was a trend toward a greater likelihood of RRB among women who did not use birth control in the year following the index child's birth (AOR: 1.67; 95% CI: 0.98-2.82). At the 3-year follow-up interview, mothers with a RRB were more likely to have adverse maternal and child outcomes. There was greater likelihood of severe maternal parenting stress (AOR: 2.29; 95% CI: 1.17-4.48), neglectful behavior toward the index child (AOR: 2.42; 95% CI: 1.41-4.18), and poor warmth toward the index child (AOR: 2.84; 95% CI: 1.71-4.42). In families with a RRB, the index child was more likely to exhibit internalizing behavior (AOR: 1.64; 95% CI: 1.04-2.58) and there was a trend toward higher odds of externalizing behavior (AOR: 1.56; 95% CI: 0.98-2.49).

CONCLUSIONS

Overall, 20% of the mothers in our sample of at-risk families had a RRB, which was far greater than the national average of 11%. RRB was associated with a greater likelihood of adverse consequences for both the mother and the index child. The lack of program effects can be traced to shortcomings in the program's design and implementation system. HSP contracts required only that family planning be introduced any time during a family's first year of enrollment. Because conception can occur very soon after the index birth, a better design would be to introduce family planning counseling early in a family's enrollment in home visiting. Another shortcoming was that, although fathers could be included in counseling, they took part in only approximately one-fifth of home visits. It is possible that program effects were attenuated in families in which the father wanted a child. In conclusion, the Hawaii HSP did not reduce RRB or alter its malleable determinants. RRB was associated with adverse outcomes for both the mother and the index child. This is particularly relevant for this population of families that are already at risk for child maltreatment, for which we have found parenting stress to be associated with abusive parenting behavior by the mother. Our findings support and broaden the rationale for the Healthy People 2010 objective to reduce RRB. We think our findings are valuable for guiding the future development of home visiting in general and this widely replicated paraprofessional model in particular.

Risk of mother-reported child abuse in the first 3 years of life

OBJECTIVE

The purpose of this research was to investigate, within an at-risk population, parent and child characteristics associated with a mother's self-reports of severe physical assault and assault on the self-esteem of the child in the first 3 years of life.

DESIGN

The study population consisted of a community-based sample of mothers of newborns identified as at-risk for child maltreatment (n=595). Families were assessed annually from the child's birth through age 3 using instruments with established psychometric properties. Independent variables investigated included: family socio-demographics, parity, mother's social support, maternal depression, maternal problem drug or alcohol use, partner violence, child's age, child's sex, low birth weight/small for gestational age (SGA), and mother's perception of child's demand level. Associations with maltreatment were examined using multivariable methods for longitudinal data.

RESULTS

Child severe physical assault was significantly associated with parent characteristics (maternal depression and partner violence); and child characteristics (SGA). Assault to the child's self-esteem was significantly associated with maternal depression, maternal illicit drug use, partner violence and mother's perception of child's demand level. Controlling for family sociodemographic characteristics did not change the associations. Likewise, while mother's perception of child demand level had an independent association with self-esteem assault, the associations described above persisted while demand level was held constant. In this high-risk sample, abuse was not associated with mother's age, education, race, parity, or household income level.

CONCLUSIONS

While characteristics such as SGA can serve as markers for increased abuse risk, they are not amenable to intervention after the child is born. However, certain other risk factors, such as maternal depression and domestic violence are malleable and should be targeted for intervention with the goal of preventing child maltreatment.

Parent-pediatrician communication about complementary and alternative medicine use for children

Anonymous self-report surveys of a convenience sample of caregivers accompanying children to the pediatrician for acute or well visits at 4 pediatric practices in the Washington, DC area from July through November 1998 were evaluated. Three hundred seventy-eight (85%) of 443 caregivers approached participated. The 348 surveys completed by parents (92%) were analyzed. As previously reported, in this sample 21% of parents used complementary and alternative medicine (CAM) for their child. Overall, 53% of parents expressed the desire to discuss CAM with their pediatrician, increasing to 75% (p<0.001) among those who used CAM themselves and 81% (p<0.01) among those who used CAM for their child. Among parents who used CAM for their child, 36% had discussed it with their pediatrician. Factors associated with increased disclosure to the pediatrician were CAM use in children younger than 6 years (p<0.05), "bioenergetic" CAM use (p<0.02), and parent CAM non-use (p<0.05). Despite parents' significant interest in discussion about CAM, few factors were associated with adequate parent-pediatrician communication.

Physical activity in urban school-aged children with asthma

OBJECTIVES

To compare the physical activity levels of children with and without asthma and evaluate predictors of activity level in children with asthma.

METHODS

Parents of 137 children with asthma and 106 controls 6 to 12 years old who attended an urban primary care pediatric clinic were interviewed by telephone. A structured survey evaluated 1 day's total activity and the number of days active in a typical week; asthma characteristics and treatment; physician advice; opportunities for physical activity; and caregiver beliefs about physical activity. The activity levels of children with and without asthma were compared. Predictors of activity level of children with asthma were evaluated.

RESULTS

Children with asthma were less active than their peers. The mean amount of daily activity differed by group: 116 (asthma) vs 146 (nonasthma) minutes; 21% (asthma) vs 9% (nonasthma) were active <30 minutes/day; and 23% (asthma) vs 11% (nonasthma) were active <3 days/week. Among children with asthma, disease severity and parental beliefs regarding exercise and asthma predicted activity level. Children with moderate or severe persistent asthma were more likely to be active <30 minutes/day (odds ratio: 3.0; confidence interval: 1.2-7.5), and children whose parents believed exercise could improve asthma were more likely to be highly active > or = 120 minutes/day (odds ratio: 2.5; confidence interval: 1.2-5.4).

CONCLUSIONS

Disease severity and parental health beliefs contribute to the lower activity level of children with asthma. Pediatricians should evaluate exercise level as an indicator of disease control and address exercise and its benefits with patients and caregivers to help achieve the goal of normal physical activity in children with asthma.

Reduced School Dropout Rates Among Adolescent Mothers Receiving School-Based Prenatal Care

BACKGROUND

Adolescent pregnancy is associated with increased school dropout rates. Dropping out amplifies the probability of persistent social and economic disadvantage. Whether school-based health centers might help reduce school absenteeism and dropout rates in this group has not been well studied.

OBJECTIVE

To examine the association of school-based prenatal services on school attendance and dropout rates.

METHODS

In this retrospective cohort study, using school rosters from an alternative school, we identified adolescents aged 18 years or younger who delivered a baby between July 1, 1995, and August 30, 1997, in Baltimore, Md. We linked school records spanning 3 years with medical records and birth certificates. School variables such as attendance and dropout rates were examined in relation to the teen's year of pregnancy and prenatal care setting (school-based vs non-school-based). Hierarchical logistic regression was used to examine effects of school-based prenatal care on dropout and promotion or graduation rates, with adjustment for baseline group differences.

RESULTS

We identified 431 predominantly African American, low-income adolescents who attended the alternative school in their pregnancy school year. In the year prior to pregnancy, most performed poorly in school and had significant absenteeism. During their pregnancy school year, teens receiving school-based prenatal care were absent 12 fewer days, as compared with those receiving non-school-based care (P =.001), and their dropout rate was half that of those receiving non-school-based care (6% vs 15%; P =.02). Hierarchical logistic regression analyses, with adjustment for baseline prepregnancy differences, demonstrated that teens receiving school-based prenatal care were less likely to drop out of school during the pregnancy year (adjusted odds ratio, 0.39; 95% confidence interval, 0.15-0.99; P =.048).

CONCLUSIONS

Absenteeism and dropout rates were reduced for pregnant adolescents receiving prenatal care at a school-based health center in an urban alternative school. Findings underscore the importance of funding and evaluating school-based health centers and other interventions that may ameliorate negative outcomes among childbearing adolescents.

Reduced low birth weight for teenagers receiving prenatal care at a school-based health center: effect of access and comprehensive care

PURPOSE

To examine and compare access to care, comprehensiveness of care, and birth outcomes for teenagers receiving prenatal care in comprehensive adolescent pregnancy programs (CAPPS) in two different settings: school-based vs. hospital-based.

METHODS

Retrospective sohort study using existing data sources: medical records and birth certificates. Using school rosters and hospital clinic databases, we identified pregnant adolescents < or =18 years old who delivered a baby between July 1, 1995 and August 30, 1997 and who received prenatal care in a school-based CAPP (SB-CAPP) or hospital-based CAPP (HB-CAPP). Process of care measures (prenatal care adequacy and comprehensive care) and outcomes (low birth weight) were examined by site of care. Logistic regression models were computed to predict the odds of low birth weight by site of prenatal care, adjusting for prenatal care adequacy, comprehensive care, and possible confounders including baseline maternal characteristics.

RESULTS

Three-hundred-ninety eligible teens were identified. Mean age was 15.9 years, 93% were African-American, 84% in school, 13% had a prior birth, and 11% were cigarette smokers. Teens receiving care in the SB-CAPP were significantly younger and more likely to be in school than those in the HB-CAPP. Overall, the two groups had similar low rates of prenatal care adequacy, but compared with teens in the SB-CAPP, those in the HB-CAPP were 1.5 times less likely to receive comprehensive care. Logistic regression analyses adjusting for baseline maternal differences showed that HB-CAPP teens were more than three times as likely to deliver a low birth weight infant compared with SB-CAPP teens (AOR 3.75; 95% CI 1.05-13.36). The increased odds of low birth weight for HB-CAPP teens attenuated when prenatal care was adequate and comprehensive (AOR-HB-CAPP: 2.31, 95% CI 0.65-8.24).

CONCLUSIONS

School-based prenatal care was associated with significantly lower odds of low birth weight compared with HB-CAPP care. Although selection bias may be a factor in this observational study, our findings suggest that these improved birth outcomes may be mediated through prenatal care adequacy and provision of comprehensive care.

Cost-effectiveness of solvent/detergent-treated fresh-frozen plasma

BACKGROUND AND OBJECTIVES

Although transfusion-transmitted infections are rare, non-infectious complications occur relatively frequently. Solvent/detergent-treated fresh-frozen plasma (SD-FFP) has been shown to reduce the frequency of both types of complication, although previous economic evaluations failed to consider non-infective events and subsequently underestimated the benefits of SD-FFP.

MATERIALS AND METHODS

A time-series analytical model was used to estimate the incremental cost/life year saved for SD-FFP compared with untreated FFP, having controlled for post-transfusion mortality and patient age. Various infective and non-infective transfusion-related complications were considered.

RESULTS

The discounted cost/life year saved for SD-FFP use in the UK was pound sterling 22,728 [95% confidence interval (95% CI): pound sterling 22,604-22,853] for neonates and pound sterling 98,465 (95% CI: pound sterling 97,924-99,005) for patients aged 70. The cost-effectiveness ratio was below pound sterling 50,000/life year saved for patients < or = 48 years of age, and below pound sterling 30,000/life year saved for those < or = 21 years of age. In transfusion recipients with no significant morbidity, the cost-effectiveness ratio was pound sterling 12,335 for neonates and pound sterling 61,692 for 70-year olds. The most important driver of cost-effectiveness was transfusion-related acute lung injury (TRALI), on account of its relatively high incidence and mortality rate.

CONCLUSIONS

Previous analyses greatly underestimated the cost-effectiveness of SD-FFP. Inclusion of non-infectious complications suggests that SD-FFP is cost-effective in patients < or = 48 years of age and in older patients with good clinical prognosis, which may justify the wider use of this technology.

Prevalence of hepatitis C virus infection in urban children

OBJECTIVES

To determine the prevalence of hepatitis C virus (HCV) infection in children with an unknown or negative human immunodeficiency virus (HIV) status attending an urban hospital pediatric primary care clinic, and to identify HCV risk factors in their mothers.

STUDY DESIGN

This was a cross-sectional study of 1034 children tested for HCV antibodies (anti-HCV) after excluding children known to be HIV-positive. We assessed maternal HCV risk factors through structured interviews with a sample of mothers (n=573) and through review of available medical records (n=347) for a subsample of mother-child pairs. Means, proportions, and 95% confidence intervals were used to estimate the prevalence of anti-HCV and maternal risk factors.

RESULTS

One child (0.1%; 95% CI, 0.002, 0.5) was anti-HCV positive. History of blood transfusion was reported by 7% of mothers and intravenous drug use (IVDU) by 1.8%. A subsample of mothers significantly underreported IVDU when compared with medical record review (1.5% vs 7.8%, P<.001).

CONCLUSIONS

Our findings suggest that universal screening of children for HCV in high-risk urban communities is not warranted. However, self-report may not be reliable for identifying mothers with a history of IVDU, for whom HCV testing is recommended.

Does a clinical pathway improve the quality of care for sickle cell anemia?

BACKGROUND

Clinical pathways are often implemented to improve care, yet their effect on quality of care and outcomes is often not evaluated. The Johns Hopkins Children's Center instituted a clinical pathway in early 1996 to improve the care for pediatric sickle cell vaso-occlusive crisis (VOC) and used a retrospective before-after study to describe how quality of care and outcomes changed after introduction of the pathway.

RESULTS

Physicians used the pathway in 43% of eligible admissions, with use decreasing over time. Patients on the pathway were more likely to receive each of its required elements than those not on the pathway (odds ratios [OR] 1.15-2.49). After pathway implementation, even patients not on the pathway were more likely to receive incentive spirometry than those admitted before pathway availability (OR 1.40). Pathway use was associated with longer length of stay (LOS) and time to oral pain medication, while readmission rates did not change.

DISCUSSION

Use of a clinical pathway improved quality of care by increasing compliance with specific care elements, with mixed results on outcomes. Pathways may improve care for all patients, including nonpathway-treated patients, by influencing underlying practice patterns. Quality improvement committees must regularly monitor outcomes after pathway implementation to evaluate the need for pathway reinforcement and refinement.

The effect of volunteer home visitation for adolescent mothers on parenting and mental health outcomes: a randomized trial

BACKGROUND

Children of adolescent mothers may suffer because of parenting inadequacies. The use of volunteer home visitors to enhance parenting skills has not been well studied.

OBJECTIVE

To evaluate the effect of a volunteer model home visitation program on adolescent parenting outcomes.

DESIGN

Randomized trial with assignment to home visitation or control group.

SETTING

Urban, African American community.

PARTICIPANTS

Adolescents aged 12 to 18 years at 28 or more weeks' gestation or who had delivered a baby in the past 6 months were recruited between February 1996 and August 1999.

INTERVENTION

Volunteers were recruited from the community and trained to implement a parenting curriculum during weekly home visits. Each volunteer was paired with one teenager.

MAIN OUTCOME MEASURE

Validated instruments measuring parenting stress, parenting behaviors, and mental health.

RESULTS

A total of 232 teenagers were successfully randomized to home visitation and control groups. At baseline, the groups were comparable on demographic, social support, and mental health measures. Almost half the teenagers had poor mental health at baseline, and high rates persisted at follow-up in both groups. In multivariate models, the home visitation group demonstrated significantly better parenting behavior scores at follow-up than did the control group (P =.01) but showed no differences in parenting stress or mental health.

CONCLUSIONS

The volunteer home visitation program significantly improved some parenting outcomes but not parental distress or poor mental health. Volunteers may be an effective means of providing parenting education, but interventions that include specific means of addressing poor mental health are likely to have greater effects.

Pediatric residents' attitudes and behaviors related to counseling adolescents and their parents about firearm safety

BACKGROUND

Firearms continue to be a major cause of mortality in adolescence. Although the American Academy of Pediatrics strongly encourages pediatricians to counsel adolescents and their parents on firearm safety, few residency programs educate their trainees in this area. More in-depth information is needed to design effective educational interventions.

OBJECTIVES

To determine the attitudes, beliefs, and practices of pediatric residents regarding firearm safety counseling and to compare their counseling practices for adolescents and parents of adolescents during health maintenance visits.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Pediatric residents from 9 programs in the mid-Atlantic region.

RESULTS

Of the 322 respondents (76% response rate), few believed that it is not a pediatrician's responsibility to counsel, that their patients are not at risk for firearm injury, and that children are safer with a gun in the home. However, only 50% reported routine counseling, and more than 20% reported almost never counseling adolescents and their parents on firearm safety. Barriers included inadequate training (38%), insufficient time (26%), and a lack of preceptor expectation (13%). The strongest predictors for counseling adolescents included the belief that gun-related media coverage influences counseling practice, level of training, and personal experience with guns in the home. The strongest predictors for counseling parents of adolescents were the belief in the media's influence on counseling practice, perceived counseling effectiveness, and discomfort with firearm safety counseling.

CONCLUSIONS

To increase counseling practices, clinical preceptors should aim to strengthen residents' comfort in counseling and to develop specific ways to enhance their perceived effectiveness in counseling parents.

Effectiveness of a high school smoking cessation program

OBJECTIVE

To evaluate the impact of a school-based smoking cessation program targeting adolescents interested in quitting.

DESIGN

Randomized clinical trial over one school year.

SETTING

Large public high school.

PARTICIPANTS

Students interested in quitting smoking.

INTERVENTION

Seventy-four students were randomized to receive either: 1) a 6-week, 8-session, classroom-based, smoking cessation curriculum designed for adolescents (n = 35) or 2) an informational pamphlet on how to quit smoking with promise of the classroom curriculum in 3 months (n = 39).

OUTCOME MEASURES

Change in smoking behavior measured by: 1) self-reported smoking cessation and exhaled carbon monoxide <6 parts per million (smoke-free); 2) self-reported quit attempts; and 3) change in cigarettes per day (cpd) at the end of the 6-week curriculum and then 4, 10, and 20 weeks later. Saliva cotinine was also measured at these points to validate these outcome measures. Analysis. Intention-to-treat.

RESULTS

Participants in the classroom group attended an average of 4.4 sessions. At the end of the curriculum, the classroom group was significantly more likely to be smoke-free (59% vs 17%), to have tried to quit smoking (82% vs 54%), and to reduce mean cpd (7.0 vs 1.0). Four weeks later, these differences persisted: smoke-free (52% vs 20%), quit attempt (85% vs 60%), and reduction in mean cpd (6.6 vs 1.6). Changes in saliva cotinine were consistent with reported outcome measures; those who were smoke-free had a significant reduction in saliva cotinine at the end of the intervention, and at 4 weeks. At 10 and 20 weeks after the curriculum, 41% and 31%, respectively, of the classroom group remained smoke-free. Once participants in the pamphlet group underwent the classroom intervention (average attendance of 2.2 sessions) their cessation rates were similar to the initial group: 31% at the end of the curriculum and 27% 10 weeks later.

CONCLUSION

A school-based curriculum for adolescent smoking cessation is more effective than an informational pamphlet alone and reduces cigarette use by adolescents. More research is needed to test the reproducibility, sustainability, and generalizability of this curriculum to offer more smoking cessation options to teenagers.

Screening for iron deficiency anemia by dietary history in a high-risk population

BACKGROUND

Iron deficiency anemia (IDA) in young children is important to identify because of its adverse effects on behavior and development. Because of costs and inconvenience associated with blood test screening and the decline in prevalence of IDA, the Institute of Medicine and the Centers for Disease Control and Prevention recommend that blood test screening for IDA be targeted to children first identified by dietary and health history.

OBJECTIVE

To evaluate a parent-completed dietary and health history as the first stage of 2-stage screening for IDA.

DESIGN AND METHODS

A cross-sectional study was conducted in inner-city clinics in children 9 to 30 months old having routine anemia screening as part of a scheduled visit. Parents completed a questionnaire and children had venous blood sampling for complete blood count and ferritin. Anemia was defined as Hb <11.0 g/dL. Iron deficiency (ID) was defined as ferritin <10 microg/L or mean corpuscular volume <70 fL and red cell distribution width >14.5%. Children were categorized into 1 of 4 groups: iron-sufficient, not anemic (ISNA); iron-sufficient, anemic (ISA); iron-deficient, not anemic (IDNA); and iron-deficient anemic (IDA). The questionnaire consisted of 15 dietary items in domains of infant diet, intake of solid food, intake of beverages, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children together with 14 historical items in domains of birth history, recent illness, chronic medical conditions, history of anemia, and maternal history. Analysis was performed on individual items, domains, and combinations of selected items.

RESULTS

In the 282 study subjects, the prevalence of anemia (35%), IDNA (7%), and IDA (8%) did not vary significantly by age. Among individual historical and dietary questions, maternal history of anemia and drinking >2 glasses of juice per day identified the highest proportion of children with IDA: 50% sensitivity (95% confidence interval [CI]: 16,81) and 77% sensitivity (95% CI: 54,89), respectively. However, specificities for these questions were 60% (95% CI: 55,65) and 22% (95% CI: 17,27), respectively. Domains of questions with the highest sensitivity for IDA were beverage intake (91%; 95% CI: 68,99) and intake of solid food (91%; 95% CI: 68,99). However, specificities of the domains were only 14% (95% CI: 10,18) and 29% (95% CI: 24,35), respectively. The dietary items used by Boutry and Needlman were 95% (95% CI: 77, 99) sensitive but only 15% (95% CI: 11,19) specific for IDA. The recommendations of the Centers for Disease Control and Prevention for health and dietary screening were 73% (95% CI: 56,92) sensitive and 29% (95% CI: 24,35) specific for IDA. The individual questions, domains of questions, and interdomain groups of questions had similar sensitivity and specificity for anemia and ID (IDA + IDNA).

CONCLUSION

In this high-risk population, neither individual nor combinations of parental answers to dietary and health questions were able to predict IDA, anemia, or ID well enough to serve as a first-stage screening test.

Use of social services by pregnant Medicaid eligible women in Baltimore

OBJECTIVES

To use linked health and social service databases to determine differences in the use of social services by pregnant women in different managed care systems.

METHODS

Comparison of service use by women enrolled in a fee-for-service primary care case management program (Maryland Access to Care or MAC), in a capitated health maintenance organization (HMO), or not assigned to managed care using six state databases. Participants included 5181 women receiving Medical Assistance (MA) and delivering in Baltimore City in 1993. Outcome measures were receipt of WIC, AFDC, and Food Stamps.

RESULTS

The overall proportions of women receiving WIC, AFDC, and Food Stamps at delivery were 52.7%, 89.2%, and 62.7%, respectively. Women enrolled in an HMO at delivery were less likely to be receiving WIC (adjusted odds ratios, 0.8, 95% CI, 0.69 to 0.93), AFDC (OR, 0.20; CI, 0.03 to 0.43 for women with prior children and OR 0.13; CI, 0.09 to 0.20 for women without prior children), and Food Stamps (OR 0.77; CI, 0.59 to 0.95 for women with prior children and OR, 0.49; CI, 0.35 to 0.67 for women without prior children) than their MAC counterparts. Women not assigned to managed care also generally were less likely than their MAC counterparts to receive WIC (OR 0.55; CI, 0.46, 0.66), AFDC (OR 1.07; CI 0.83, 1.30 for women with prior children and OR 0.24; CI 0.18, 0.34 for women without prior children), and Food Stamps (OR 0.31; CI 0.08, 0.55 for women with prior children and OR 0.31; CI 0.23, 0.41 for women without prior children).

CONCLUSIONS

Although many low-income pregnant women qualify for select social services, receipt of WIC and Food Stamps was low. Increasing efforts are needed by managed care systems and public health agencies to ensure delivery of appropriate services for women.

Relationship between primary care practices in medical school admission and the matriculation of underrepresented-minority and female applicants

PURPOSE

To determine whether primary care-oriented (generalist) admission practices at U.S. medical schools address physician workforce diversity issues by resulting in the admission of more members of underrepresented-minority populations or more women.

METHOD

The authors performed cross-sectional, secondary analyses of databases from the Association of American Medical Colleges (AAMC). The independent variables were four generalist admission practices: generalist admission committee chair, greater representation of generalists on admission committee, offering preferential admission to likely generalists, and having a premedical recruitment activity targeting likely generalists. The control variable was public/private school ownership. The dependent variables were the mean ages of the matriculating classes and the proportions of students at each school who were African American, (total) underrepresented minorities, women, and married.

RESULTS

Ninety-five percent of medical schools completed the AAMC's Survey of Generalist Physician Initiatives in either 1993 and 1994; 94% of matriculants replied to the AAMC's 1994 Matriculating Student Questionnaire. In multivariable analyses, no admission practice was associated with percentages of African Americans, total underrepresented minorities, or women.

CONCLUSIONS

Schools with primary care-oriented admission practices did not admit greater percentages of underrepresented-minority students or women. Additional efforts may be required to attract and admit minority and female applicants.

Ipratropium bromide added to asthma treatment in the pediatric emergency department

OBJECTIVE

To determine if the addition of ipratropium bromide to the emergency department (ED) treatment of childhood asthma reduces time to discharge, number of nebulizer treatments before discharge, and the rate of hospitalization.

METHODS

Patients >12 months of age were eligible if they were to be treated according to a standardized ED protocol for acute asthma with nebulized albuterol (2.5 mg/dose if weight <30 kg, otherwise 5 mg/dose) and oral prednisone or prednisolone (2 mg/kg up to 80 mg). Subjects were randomized to receive either ipratropium (250 microg/dose) or normal saline (1 mL/dose) with each of the first three nebulized albuterol doses. Further treatment after the first hour was determined by physicians blinded to subject group assignment. Records were reviewed to determine the length of time to discharge home from the ED, number of doses of albuterol given before discharge, and the number of patients admitted to the hospital.

RESULTS

Four hundred twenty-seven patients were randomized to ipratropium or control groups; these groups were similar in all baseline measures. Among patients discharged from the ED, ipratropium group subjects had 13% shorter treatment time (mean, 185 minutes, vs control, 213 minutes) and fewer total albuterol doses (median, three, vs control, four). Admission rates did not differ significantly (18%, vs control, 22%).

CONCLUSIONS

The addition of three doses of ipratropium to an ED treatment protocol for acute asthma was associated with reductions in duration and amount of treatment before discharge.

Is oral albuterol effective for acute cough in non-asthmatic children?

Fifty-nine non-asthmatic children with acute cough were randomized to receive oral albuterol or placebo for 7 d. There was a similar, rapid rate of resolution of acute cough for the two groups, but more shaking or trembling in those treated with albuterol (5/30 vs 0/29; p = 0.05). In ambulatory children with acute cough who have no history of asthma and a normal chest examination, oral albuterol does not reduce the frequency or duration of cough.

Evaluation of Hawaii's Healthy Start Program

Hawaii's Healthy Start Program (HSP) is designed to prevent child abuse and neglect and to promote child health and development in newborns of families at risk for poor child outcomes. The program operates statewide in Hawaii and has inspired national and international adaptations, including Healthy Families America. This article describes HSP, its ongoing evaluation study, and evaluation findings at the end of two of a planned three years of family program participation and follow-up. After two years of service provision to families, HSP was successful in linking families with pediatric medical care, improving maternal parenting efficacy, decreasing maternal parenting stress, promoting the use of nonviolent discipline, and decreasing injuries resulting from partner violence in the home. No overall positive program impact emerged after two years of service in terms of the adequacy of well-child health care; maternal life skills, mental health, social support, or substance use; child development; the child's home learning environment or parent-child interaction; pediatric health care use for illness or injury; or child maltreatment (according to maternal reports and child protective services reports). However, there were agency-specific positive program effects on several outcomes, including parent-child interaction, child development, maternal confidence in adult relationships, and partner violence. Significant differences were found in program implementation between the three administering agencies included in the evaluation. These differences had implications for family participation and involvement levels and, possibly, for outcomes achieved. The authors conclude that home visiting programs and evaluations should monitor program implementation for faithfulness to the program model, and should employ comparison groups to determine program impact.

Associations between primary care-oriented practices in medical school admission and the practice intentions of matriculants

PURPOSE

To assess associations of primary-care-oriented medical school admission practices with matriculants practice intentions.

METHOD

The authors performed cross-sectional, secondary analyses of databases from the Association of American Medical Colleges (AAMC). The independent variables were four medical school admission practices. The control variable was school ownership (public vs private). The dependent variables were the proportions of matriculants at each school interested in generalism, rural practice, and locating in a socioeconomically deprived area.

RESULTS

One hundred and twenty medical schools (95%) completed the AAMC's Survey of Generalist Physician Initiatives in either 1993 or 1994; 94% of matriculants replied to the AAMC's 1994 Matriculating Student Questionnaire. Twenty-five percent of the schools had admission committee chairs who were generalists, half had over 25% generalists on their admission committees, 64% gave admission preference to students likely to become generalists, and 33% reported premedical recruitment efforts that targeted applicants likely to become generalists. In multivariable analyses, premedical recruitment efforts and public school ownership (all p < .01) were associated with greater interest of matriculants in both generalism and rural practice.

CONCLUSIONS

Public medical schools and schools with premedical recruitment activities targeting future generalists admitted greater proportions of students interested in primary care and rural practice.

Modelling different approaches to the management of upper gastrointestinal disease

A treatment algorithm for the management of upper gastrointestinal (UGI) disease in general practice has been developed by an international group of general practitioners [the International Gastro Primary Care Group (IGPCG)]. When the algorithm was evaluated to consider the overall cost per patient, it was shown to offer savings over current practice in the UK. Adjustments to the algorithm have been proposed, usually on the basis of variations in the place and timing of Helicobacter pylori testing and eradication, with or without endoscopy. This paper evaluates the current cost of UGI disease in the UK, the base IGPCG algorithm and the 5 major alternative scenarios. The original IGPCG algorithm was the least costly option of all those considered, with additional H. pylori testing for all patients with suspected ulcer being the second least expensive option. Routine endoscopies for all patients or for all patients aged more than 45 years were the most expensive scenarios and would require a 16- or 13-fold increase, respectively, in the provision of endoscopy services in the UK. The use of routine endoscopy for all patients aged more than 45 years who were presenting with UGI symptoms for the first time was a mid-priced option, but would still require a 5-fold increase in the provision of endoscopy services. The modelling process highlights the fact that early stratification of patients into diagnostic and treatment groups, on the basis of history and symptom cluster, is a less costly approach than that of early routine endoscopy or H. pylori testing. If H. pylori testing is to be used routinely, then the least costly way is to apply the method to those patients who have symptoms that are more indicative of ulcer disease. All the scenarios considered resulted in lower drug costs than current average UK drug costs per patient per year, and in fewer prescriptions and general practitioner surgery visits per patient. There are several ways in which the management of UGI disease in the UK could be improved with regard to costs and resource utilisation, some of which are presented here. This process emphasises the value of modelling techniques to investigate the consequences of different patient management scenarios.