Holly Grason

Are two doctors better than one? Women's physician use and appropriate care.

This study examines nonelderly womens concurrent use of two types of physicians (generalists and obstetrician-gynecologists) for regular health care and associations with receipt of preventive care, including a range of recommended screening, counseling, and heart disease prevention services. Data are from the 1999 Womens Health Care Experiences Survey conducted in Baltimore, Maryland, using random digit dialing (N = 509 women ages 18 to 64). Key findings are: 58% of women report using two physicians (a generalist and an ob/gyn) for regular care; seeing both a generalist and an ob/gyn, compared with seeing a generalist alone, is consistently associated with receiving more clinical preventive services, including screening, counseling, and preventive services related to heart disease. Because seeing an ob/gyn in addition to a generalist physician is associated with receiving recommended preventive services (even for heart disease), the findings suggest that non-elderly women who rely on a generalist alone may receive substandard preventive care. The implications for womens access to ob/gyns and for appropriate design of womens primary care are discussed.

Early Childhood Health Promotion and Its Life Course Health Consequences

OBJECTIVE To explore whether health promotion efforts targeted at preschool-age children can improve health across the life span and improve future economic returns to society. METHODS We selected 4 health topics to review-tobacco exposure, unintentional injury, obesity, and mental health-because they are clinically and epidemiologically significant, and represent the complex nature of health problems in this early period of life. The peer-reviewed literature was searched to assess the level of evidence for short- and long-term health impacts of health promotion and disease prevention interventions for children from before birth to age 5. This review sought to document the monetary burden of poor child health, the cost implications of preventing and treating child health problems, and the net benefit of the interventions. RESULTS The evidence is compelling that these 4 topics-tobacco exposure, unintentional injury, obesity, and mental health-constitute a significant burden on the health of children and are the early antecedents of significant health problems across the life span. The evidence for the cost consequences of these problems is strong, although more uneven than the epidemiological data. The available evidence for the effectiveness of interventions in this age group was strongest in the case of preventing tobacco exposure and injuries, was limited to smaller-scale clinical interventions in the case of mental health, and was least available for efforts to prevent obesity among preschoolers. CONCLUSIONS Currently available research justifies the implementation of health interventions in the prenatal to preschool period-especially to reduce tobacco exposure and prevent injuries. There is an urgent need for carefully targeted, rigorous research to examine the longitudinal causal relationships and provide stronger economic data to help policy makers make the case that the entire society will benefit from wise investment in improving the health of preschool-age children and their families.

Healthy Steps for Young Children: Sustained Results at 5.5 Years

OBJECTIVE. We sought to determine whether Healthy Steps for Young Children has sustained treatment effects at 5.5 years, given early findings demonstrating enhanced quality of care and improvements in selected parenting practices. METHODS. Healthy Steps was a clinical trial that incorporated developmental specialists and enhanced developmental services into pediatric care in the first 3 years of life. A total of 5565 children were enrolled at birth and followed through 5.5 years. Healthy Steps was evaluated at 6 randomization and 9 quasi-experimental sites. Computer-assisted telephone interviews were conducted with mothers when Healthy Steps children were 5.5 years of age. Outcomes included experiences seeking care, parent response to child misbehavior, perception of childs behavior, and parenting practices to promote development and safety. Logistic regression was used to estimate overall effects of Healthy Steps, adjusting for site and baseline demographic characteristics. RESULTS. A total of 3165 (56.9%) families responded to interviews (usual care: n = 1441; Healthy Steps: n = 1724). Families that had received Healthy Steps services were more satisfied with care (agreed that pediatrician/nurse practitioner provided support, 82.0% vs 79.0%; odds ratio: 1.25 [95% confidence interval: 1.02–1.53]) and more likely to receive needed anticipatory guidance (54.9% vs 49.2%; odds ratio: 1.33 [95% confidence interval: 1.13–1.57]) (all P < .05). They also had increased odds of remaining at the original practice (65.1% vs 61.4%; odds ratio: 1.19 [95% confidence interval: 1.01–1.39]). Healthy Steps families reported reduced odds of using severe discipline (slap in face/spank with object, 10.1% vs 14.1%; odds ratio: 0.68 [95% confidence interval: 0.54–0.86]) and increased odds of often/almost always negotiating with their child (59.8% vs 56.3%; odds ratio: 1.20 [95% confidence interval: 1.03–1.39]). They had greater odds of reporting a clinical or borderline concern regarding their childs behavior (18.1% vs 14.8%; odds ratio: 1.35 [95% confidence interval: 1.10–1.64]) and their child reading books (59.4% vs 53.6%; odds ratio: 1.16 [95% confidence interval: 1.00–1.35]). There were no effects on safety practices. CONCLUSIONS. Sustained treatment effects, albeit modest, are consistent with early findings. Universal, practice-based interventions can enhance quality of care for families with young children and can improve selected parenting practices beyond the duration of the intervention.

A New Framework for Childhood Health Promotion: The Role of Policies and Programs in Building Capacity and Foundations of Early Childhood Health

Although the connection between early life experiences and later health is becoming increasingly clear, what is needed, now, is a new organizing framework for childhood health promotion, grounded in the latest science. We review the evidence base to identify the steps in the overall pathway to ensuring better health for all children. A key factor in optimizing health in early childhood is building capacities of parents and communities. Although often overlooked, capacities are integral to building the foundations of lifelong health in early childhood. We outline a framework for policymakers and practitioners to guide future decision-making and investments in early childhood health promotion.

An intersection of women’s and perinatal health: the role of chronic conditions

This paper has three objectives: 1) to review data on the prevalence of chronic disease among women of reproductive age; 2) to establish that chronic diseases are an important influence on perinatal health; and 3) to emphasize opportunities where womens health and perinatal health can intersect. This involves broadening strategies aimed at improving perinatal health to emphasize a womans overall health, regardless of childbearing status or plans, and using perinatal health care as a bridge to ongoing care for women. These issues are discussed in the context of a continuum often used to organize perinatal health interventions.

State school policies and youth obesity.

The objective of this study was to examine relations between state-level school policies and childhood obesity for youth ages 10–17 years. Secondary analysis of the 2003–2006 School Nutrition Environment State Policy Classification System, 2003–2007 Physical Education Related State Policy Classification System, and 2003 and 2007 National Surveys of Children’s Health was performed. Eleven nutrition and 5 physical education (PE) domains were examined for elementary (ES), middle (MS), and high school (HS) children. Logistic regression models examined the association of policies on obesity prevalence in 2007 as well as change scores for the policy assessments. Scores for 5 of 11 nutrition domains and 4 of 5 PE domains increased between 2003 and 2006–2007. Controlling for individual, family and neighborhood factors, nutrition policies were positively associated with the odds of 2007 obesity in 3 ES and 2 MS domains and negatively associated with 1 HS domain. Adjusted positive associations also were observed between 2 ES and 1 MS PE policy domains and 2007 obesity. Controlling for covariates, nutrition policy change scores showed positive associations between increases in 1 ES and 1MS domain, and negative associations with 1 ES and 1 HS domain and 2007 obesity. PE policy change scores showed positive adjusted associations between increases in 2 ES, 2 MS and 1 HS domains and 2007 obesity. The findings indicate that state-level school health policies are associated with childhood obesity after adjusting for related factors, suggesting that states with higher obesity levels have responded with greater institution of policies.

Educating the Next Generation of Pediatricians in Urban Health Care: The Anne E. Dyson Community Pediatrics Training Initiative

To improve the health of children who are exposed to urban health risks, there has been a national recognition of the need for better models of training pediatricians. In 2000, in response to this need, the Dyson Foundation launched a new residents-training model that focuses on community health and advocacy, The Anne E. Dyson Community Pediatrics Training Initiative (the Initiative). The Initiative is made up of 12 programs at ten sites, which are working in their communities to improve the health of the children. At its core are five objectives: to equip residents with tools and knowledge to provide community-based health care, to make use of community resources so that residents learn to practice as medical home providers, to engage residents in the communities in which they work, to develop meaningful partnerships between departments of pediatrics and their communities, and to enhance pediatrics training through interdisciplinary collaborations among schools and departments. Curricular approaches at the participating sites differ slightly, but all have explicitly incorporated teaching community pediatrics into their standard rotations and continuity clinics. The authors showcase the programs of the Initiative and explore how the programs have sought buy-in from their parent institutions, faculty, residents, and communities.

The nationwide evaluation of fetal and infant mortality review (FIMR) programs: development and implementation of recommendations and conduct of essential maternal and child health services by FIMR programs.

Objective: An evaluation of fetal and infant mortality review (FIMR) programs nationwide was conducted to characterize their unique role in improving the system of perinatal health care. The aim of this paper is to examine intermediate outcomes of the FIMR, in particular the development and implementation of recommendations produced by the FIMRs and the conduct of essential MCH services by the FIMRs. Methods: We report on 74 FIMRs whose communities were selected for the nationwide evaluation and for whom we had data from the FIMR director or comparable respondent. We focus on the recommendations of the FIMRs and the essential maternal and child health (MCH) services conducted by the FIMRs as intermediate outcomes (or outputs) and then examine how selected characteristics of the FIMR may influence these. Results: FIMRs developed recommendations on a broad range of topics but there were some areas for which nearly all programs had developed recommendations. The FIMRs relied primarily on strategies related to programs and practices, with few FIMRs reporting attention to policy-oriented approaches. Implementation of recommendations was high. Factors that influenced likelihood of implementing recommendations and conduct of essential MCH services included structure of the FIMR and training received by FIMR directors and staff. Conclusions: The focus of FIMR recommendations and the likelihood of implementation vary across FIMRs as does the conduct of essential MCH services. FIMR team structure and training of the director and staff are important areas to consider in efforts to maximize the impact of FIMR.

FIMR and Other Mortality Reviews as Public Health Tools for Strengthening Maternal and Child Health Systems in Communities: Where Do We Need to Go Next?

This article examines FIMR in relationship to two other maternal and child health mortality reviews—child fatality review (CFR) and maternal mortality review (MMR), and explores how their approaches to reviewing deaths can complement one another. Identifying opportunities for collaboration among these case review methodologies may lead to greater efficiencies at the local and state levels and strengthen the case review approach as a public health tool for improving maternal and child health outcomes. To enable comparative analysis, a table was constructed that identifies the purpose, structure, and process features of each case review approach. This was followed by an examination of two possible ways to improve maternal and child mortality review processes in states: 1) better coordination; and 2) improving each individual process through adapting and adopting promising practices from the others. A discussion is also provided of the state Title V role in facilitating both the coordination of reviews and the process of sharing best practices. Given the similarities that exist among the three MCH mortality reviews, it is important to view each review as one component of a larger system of maternal and child health death reviews. Implementing widely the recommendations generated by these reviews may increase the likelihood of improvements in services and systems on behalf of women and children.

Reducing Exposure to Environmental Toxicants Before Birth: Moving from Risk Perception to Risk Reduction

In this study, we considered approaches to reducing maternal exposure to hazardous environmental toxicants, focusing on risk communication to pregnant women and providers, but also considering identification of environmental toxicants in the community and reduction of environmental toxicants. We addressed the following questions: (1) What do pregnant women and their providers know about environmental toxicants and perinatal health? and (2) What policy strategies are needed (should be considered) to move forward in risk reduction in this area? We reviewed the literature on knowledge of pregnant women and providers regarding these issues. While there is limited research on what pregnant women and their providers know about environmental toxicants and perinatal health, there is evidence of reproductive and perinatal toxicity. This article describes a wide range of policy strategies that could be implemented to address environmental toxicants in the context of perinatal health. Effective leadership in this area will likely require collaboration of both environmental health and maternal and child health leaders and organizations.