Search

Competing Interests: Competing Interests: none declared.

Background: COVID-19 has impacted on healthcare provision. Anecdotally, investigations for children with inflammatory bowel disease (IBD) have been restricted, resulting in diagnosis with no histological confirmation and potential secondary morbidity. In this study, we detail practice across the UK to assess impact on services and document the impact of the pandemic., Methods: For the month of April 2020, 20 tertiary paediatric IBD centres were invited to contribute data detailing: (1) diagnosis/management of suspected new patients with IBD; (2) facilities available; (3) ongoing management of IBD; and (4) direct impact of COVID-19 on patients with IBD., Results: All centres contributed. Two centres retained routine endoscopy, with three unable to perform even urgent IBD endoscopy. 122 patients were diagnosed with IBD, and 53.3% (n=65) were presumed diagnoses and had not undergone endoscopy with histological confirmation. The most common induction was exclusive enteral nutrition (44.6%). No patients with a presumed rather than confirmed diagnosis were started on anti-tumour necrosis factor (TNF) therapy.Most IBD follow-up appointments were able to occur using phone/webcam or face to face. No biologics/immunomodulators were stopped. All centres were able to continue IBD surgery if required, with 14 procedures occurring across seven centres., Conclusions: Diagnostic IBD practice has been hugely impacted by COVID-19, with >50% of new diagnoses not having endoscopy. To date, therapy and review of known paediatric patients with IBD has continued. Planning and resourcing for recovery is crucial to minimise continued secondary morbidity., Competing Interests: Competing interests: RH has received consultancy or speaker’s fees and travel support from Nutricia and 4D pharma. All remaining authors declare no competing interests related to this manuscript., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The area of mental health is directly affected by the pandemic and its consequences, for various reasons: 1-the pandemic triggered a global lockdown, with dramatic socioeconomic and therefore psychosocial implications; 2-mental health services, which treat by definition a fragile population from the psychological, biological and social points of view, have a complex organizational frame, and it was expected that this would be affected (or overwhelmed) by the pandemic; 3-mental health services should, at least in theory, be able to help guide public health policies when these involve a significant modification of individual behaviour. It was conducted a narrative review of the publications produced by European researchers in the period February-June 2020 and indexed in PubMed. A total of 34 papers were analyzed, which document the profound clinical, organizational and procedural changes introduced in mental health services following this exceptional and largely unforeseen planetary event.Among the main innovations recorded everywhere, the strong push towards the use of telemedicine techniques should be mentioned: however, these require an adequate critical evaluation, which highlights their possibilities, limits, advantages and disadvantages instead of simple triumphalist judgments. Furthermore, should be emphasized the scarcity of quantitative studies conducted in this period and the absence of studies aimed, for example, at exploring the consequences of prolonged and forced face-to-face contact between patients and family members with a high index of "expressed emotions".

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Background: There is little evidence on the child and family factors that affect the intensity of care use by children with complex problems. We therefore wished to identify changes in these factors associated with changes in care service use and its intensity, for care use in general and psychosocial care in particular., Methods: Parents of 272 children with problems in several life domains completed questionnaires at baseline (response 69.1%) and after 12 months. Negative binominal Hurdle analyses enabled us to distinguish between using care services (yes/ no) and its intensity, i.e. number of contacts when using care., Results: Change in care use was more likely if the burden of adverse life events (ALE) decreased (odds ratio, OR = 0.94, 95% confidence interval, CI = 0.90-0.99) and if parenting concerns increased (OR = 1.29, CI = 1.11-1.51). Psychosocial care use became more likely for school-age children (vs. pre-school) (OR = 1.99, CI = 1.09-3.63) if ALE decreased (OR = 0.93, CI = 0.89-0.97) and if parenting concerns increased (OR = 1.26, CI = 1.10-1.45). Intensity of use (>0 contacts) of any care decreased when ALE decreased (relative risk, RR = 0.95, CI = 0.92-0.98) and when psychosocial problems became less severe (RR = 0.38, CI = 0.20-0.73). Intensity of psychosocial care also decreased when severe psychosocial problems became less severe (RR = 0.39, CI = 0.18-0.84)., Conclusions: Changes in care-service use (vs. no use) and its intensity (>0 contacts) are explained by background characteristics and changes in a child's problems. Care use is related to factors other than changes in its intensity, indicating that care use and its intensity have different drivers. ALE in particular contribute to intensity of any care use., Competing Interests: The authors have declared that no competing interests exist.

Objective: The rising prevalence of autism spectrum disorder (ASD) underscores the importance of access to evidence-based interventions such as applied behavior analysis (ABA). Anecdotal evidence suggests limitations in the supply of ABA providers, but data remain scarce. The authors provide the first known examination of the supply of certified ABA providers in the United States., Methods: Using 2018 data from the Behavior Analyst Certification Board, the authors compared the per capita supply of certified ABA providers in each state with a benchmark established using the Board's guidelines. Additionally, the authors examined state and regional variations in the supply of certified ABA providers., Results: The per capita supply of certified ABA providers fell below the benchmark in 49 states and was higher in the Northeast than in other regions (p<0.001)., Conclusions: New workforce policies are needed to increase the supply of certified ABA providers to meet the needs of youths with ASD.

This study aimed to evaluate child health needs in South Korea and the country's healthcare system capacities to meet them. A comprehensive needs assessment was performed by reviewing child health programs in Korea, followed by focus group discussions and individual interviews with multiple health experts and practitioners. Analysis of the meeting and interview transcripts were identified seven major domains of child health needs and healthcare system capacities. Comparison of child health needs and healthcare system capacities revealed that a much-needed linkage system between child health resources and preventive healthcare services is lacking. A new government policy to integrate current child health programs with high-quality preventive care is required.

Background: Basic and comprehensive emergency obstetric care services in Pakistan remain a challenge considering continued high burden of maternal and newborn mortality. This study aimed to assess the availability of emergency obstetric and newborn care in Sindh Province of Pakistan., Methods: This cross-sectional survey was conducted in twelve districts of the Sindh province in Pakistan. The districts were selected based on the maternal neonatal and child health indicators. Data were collected from 63 public-sector health facilities including district, Taluka (subdistrict) headquarters hospitals and rural health centers. Basic and comprehensive emergency obstetric newborn care services were assessed through direct observations and interviews with the heads of the health facilities by using a World Health Organization pretested and validated data collection tool. Participants interviewed in this study included the managers and auxiliary staff and in health facilities., Results: Availability of caesarean section (23, 95% C.I. 14.0-35.0) and blood transfusion services (57, 95% CI. 44.0-68.0), the two components of comprehensive emergency obstetric and newborn care, was poor in our study. However, assessment of the seven components of basic emergency obstetric and newborn services showed that 92% of the health facilities (95% C.I. 88.0-96.0) had parenteral antibiotics, 90%, (95% C.I. 80.0-95.0) had oxytocin, 92% (95% CI 88.0-96.0) had manual removal of the placenta service, 87% (95%, C.I. 76.0-93.0) of the facilities had staff who could remove retained products of conception, 82% (95% C.I. 71.0-89.0) had facilities for normal birth and 80% (95% C.I. 69.0-88.0) reported presence of neonatal resuscitation service., Conclusion: Though the basic obstetric and newborn services were reasonably available, comprehensive obstetric and newborn services were not available as per the World Health Organization's standards in the surveyed public health facilities. Ensuring the availability of caesarean section and blood transfusion services within these facilities may improve population's access to these essential services around birth.

Objectives: To analyze the health care network for at-risk infants in the western region of the city of São Paulo, with the primary health care as coordinator, and to compare the presence and extension of attributes of primary health care in the services provided, according to the service management model (Family Health Strategy and traditional basic health units)., Methods: A survey was conducted with all at-risk infants born in the western region of São Paulo between 2013 and 2014. The children were then actively searched for a later application of the PCATool - child version. The total of 233 children were located in the territory; 113 guardians agreed to participate, and 81 composed the final sample., Results: Regarding the results of PCATool for overall and essential scores, the units with Family Health Strategy were better evaluated by users, when compared with traditional basic health units, showing a statistically significant difference. However, these scores were low for both management models. Regarding attributes, the Family Health Strategy presented better performance compared with traditional basic health units for most of them, except for coordination of information systems. Of ten assessed attributes, seven reached values ≥6.6 for Family Health Strategy and two for the traditional basic health unit., Conclusions: Regardless of the type of management model, low overall and essential scores were found, indicating that guardians of at-risk infants rated some attributes as unsatisfactory, with emphasis on accessibility, integrality and family guidance. Such a performance may have negative consequences for the quality and integrality of these infants' health care.

Objectives In order to improve maternal and neonatal outcomes, it is important to understand how to maximise the utilisation of MNCH services. The supply side (service-driven) factors affecting access to MNCH services are more commonly studied and are better understood than the demand side (community led) factors. The aim of this study was to identify demand and supply determinants of access to MNCH services in Malawi. Methods Research was conducted in two districts of the Central Region of Malawi (Nkhotakota & Mchinji). Qualitative interviews (n = 85) and focus group discussions (n = 20) were conducted with a range of community members, leaders and health workers. Data were managed in NVivo (v10) and analysed using framework analysis, using Levesque et al. (2013) access framework. Results Community members clearly recognise their need for and seek out MNCH care from the formal health system. Women experience difficulties reaching health services and when reached find them limited, characterised by many indirect costs. There are many technical and interpersonal deficits, which results in poor satisfaction and reportedly poor outcomes for women. Conclusions for practice Women are seeking and utilising MNCH services which they find under-resourced and unwelcoming. Utilising the Levesque et al. (2013) framework, a granular analysis of demand and supply factors has identified the many challenges that remain to achieving equitable access to MNCH services in Malawi. Community members experience lack of availability, acceptability and appropriateness of these essential services.

Objective: To compare health care use and spending in children using vs not using respiratory medical equipment and supplies (RMES)., Study Design: Cohort study of 20 352 children age 1-18 years continuously enrolled in Medicaid in 2013 from 12 states in the Truven Medicaid MarketScan Database; 7060 children using RMES were propensity score matched with 13 292 without RMES. Home RMES use was identified with Healthcare Common Procedure Coding System and International Classification of Diseases codes. RMES use was regressed on annual per-member-per-year Medicaid payments, adjusting for demographic and clinical characteristics, including underlying respiratory and other complex chronic conditions., Results: Of children requiring RMES, 47% used oxygen, 28% suction, 22% noninvasive positive-pressure ventilation, 17% tracheostomy, 8% ventilator, 5% mechanical in-exsufflator, and 4% high-frequency chest wall oscillator. Most children (93%) using RMES had a chronic condition; 26% had ≥6. The median per-member-per-year payments in matched children with vs without RMES were $24 359 vs $13 949 (P < .001). In adjusted analyses, payment increased significantly (P < .001 for all) with mechanical in-exsufflator (+$2657), tracheostomy (+$6447), suction (+$7341), chest wall oscillator (+$8925), and ventilator (+$20 530). Those increased payments were greater than the increase associated with a coded respiratory chronic condition (+$2709). Hospital and home health care were responsible for the greatest differences in payment (+$3799 and +$3320, respectively) between children with and without RMES., Conclusion: The use of RMES is associated with high health care spending, especially with hospital and home health care. Population health initiatives in children may benefit from consideration of RMES in comprehensive risk assessment for health care spending., (Copyright © 2018. Published by Elsevier Inc.)

Children in regional, rural and remote areas have less access to services than those living in urban areas. Practitioners serving children with a hearing loss have attempted to address this gap, however there are few studies investigating service access and experiences of non-metropolitan families and professionals. This systematic review evaluates the literature on service provision to children with a hearing loss living in regional, rural and remote areas of Australia. A search of five databases, the gray literature and a prominent author located 37 relevant documents. The journal articles were rated for quality and the findings of all documents were themed. The evidence from this review indicates that children with a hearing loss living in regional, rural and remote Australia experience reduced quality and frequency of service. Further investigation is needed to identify the accessibility and suitability of services for children with a hearing loss in non-metropolitan areas.

This study examined the effect of reproductive and child health (RCH) services on fertility and child mortality in the districts of Uttar Pradesh. It specifically measured the effect of antenatal care, medical assistance at birth, child immunization and use of modern methods of contraception on Total Fertility Rate (TFR), Infant Mortality Rate (IMR) and Under-five Morality Rate (U5MR) before and after the National Rural Health Mission (NRHM) period. Data from the 2002-04 District Level Household Survey (DLHS-2), 2012-13 Annual Health Survey (AHS) and the 2001 and 2011 Censuses of India were used. The TFR and U5MR were estimated from the Census of India with district as the unit of analysis. Descriptive statistics, composite indices, random- and fixed-effects models and difference-in-difference models were used to understand the effect of RCH services on the reduction in TFR, IMR and the U5MR. The results suggest large inter-district variations in the coverage of RCH services in the state. During the post-NRHM period, improvement was highest in safe delivery followed by immunization coverage and antenatal care and least for contraceptive use in most districts. The relative ranking of districts has not changed much over time. In 2002-04, the RCH Index was highest in Lucknow (0.442) followed by Ballia and least in Kaushambi (0.115). By 2012-13, it was highest in Jhansi (0.741) and lowest in Shrawasti (0.241). The districts of Kaushambi, Unnao, Mahoba, Banda and Hardoi performed better in the RCH Index over time, while Ballia, Gautam Buddha Nagar, Kanpur Nagar, Pratapgarh and Sonbhadra remained poor. The RCH service coverage and demographic outcomes were poor in seven districts, particularly those in eastern and western Uttar Pradesh. The regression analyses suggest that the RCH Index exerts greater influence on the reduction in IMR and U5MR, while female literacy exerts greater influence on the reduction in TFR. The results of the hybrid model suggest that a 10% change in RCH Index would lead to a 3 point decline in IMR, and a 10% increase in female literacy would lead to a 0.2 point decline in TFR. The study suggests continuing investment in female education and RCH services with a greater focus on poor-performing districts to realize demographic and health targets.

Introduction: In recent years, admission of critical newborn infants (NBIs) to the neonatal intensive care unit of Hospital Garrahan (HG) has been limited due to the hospitalization of infants younger than 30 days old through spontaneous demand for services. This is probably a multifactorial situation, and one of its causes is a lack of regionalization, which results in an inadequate use of resources or a distorted use of resources intended for more complex care., Objective: To establish the profile of NBIs who make a spontaneous demand for services at HG and to assess the level of care required based on their medical condition., Materials and Methods: Cross-sectional study. All infants < 30 days old who sought care at HG in a period of 12 months were assessed. The analysis included clinical characteristics of NBIs, prior visits, parental reason for consultation at HG, and whether NBIs could have been seen at a primary or secondary care facility., Results: A total of 307 consultations were analyzed; NBI age was 18 days ± 7.6. Of these, 78% required hospitalization. The most common reason for hospitalization was acute respiratory tract infection. Thirty-five percent had health insurance coverage; 54% had sought care more than once at a different facility. Only 15% of NBIs had a highly complex condition that should have actually been solved at HG., Conclusion: Based on the analysis of NBIs seen at HG through spontaneous demand for services, a high requirement of hospitalization for low and medium complexity pathologies was observed.

Background: Approximately 13% of Canadian mothers report difficulty accessing health care for their infants, yet little is known about the factors associated with difficulty. Therefore, we examined factors associated with difficulty accessing non-routine health care for Canadian infants, from birth to 14 months of age, as reported by their mothers., Methods: Data was drawn from the Maternity Experiences Survey (MES), a cross-sectional, nationally representative survey of mothers who gave birth between November 2005 and May 2006, aged 15 years or older, and lived with their infants at the time of survey administration. A multivariable logistic regression analysis was conducted to determine factors associated with reporting difficulty, with difficulty defined as a mother reporting it being somewhat or very difficult to access a health care provider., Results: Analysis of 2832 mothers who reported needing to access a health care provider for their infant for a non-routine visit found that 13% reported difficulty accessing a provider. Factors associated with reporting difficulty were: residing in Quebec (aOR 1.89, 95% CI: 1.31-2.73), being an immigrant (aOR 1.58, 95% CI: 1.10-2.27), mistimed pregnancy (aOR 1.44, 95% CI: 1.05-1.98), low level of social support (aOR 1.69, 95% CI: 1.05-2.73), good health (aOR 1.88, 95% CI: 1.43-2.47), postpartum depression symptoms (aOR 1.55, 95% CI: 1.02-2.37) and a self-reported 'too-short' postpartum hospital stay (aOR 1.69, 95% CI: 1.21-2.35). Additionally, accessing care for an infant with a birth weight of 2500 g or more (aOR 2.43, 95% CI: 1.02-5.82), was associated with reporting difficulty. Household income, mothers' level of education, marital status, Aboriginal ethnicity, and size of community of residence were not associated with difficulty accessing care., Conclusions: Ease of health care access for Canadian infants is not equal, suggesting that efforts to improve access should be tailored to groups facing increased difficulties.

The long term effects of untreated mental health need for individuals, families and society has prompted a number of federal policy statements encouraging the use of evidence-based programs (EBP) in children's healthcare. However, among other challenges of evidence-based practice implementation, states often do not know where to make investments based on population need. In this paper we present the use of a Geographic Information System approach to undertake a mental health needs assessment for Washington State. Our study found that this technology can be beneficially applied to conducting needs assessment for EBP implementation, and we provide recommendations for future applications.

Despite concern about access to mental health (MH) services for youth, little is known about the specialty treatment infrastructure serving this population. We used national data to examine which types of MH treatment facilities (hospital- and community-based) were most likely to offer youth services and which types of communities were most likely to have this infrastructure. Larger (p < 0.001) and privately owned (p < 0.001) facilities were more likely to offer youth services. Rural counties, counties in which a majority of residents were nonwhite, and/or counties with a higher percentage of uninsured residents were less likely to have a community-based MH treatment facility that served youth (p < 0.001).

South Africa (SA) has emerged from the Millennium Development Goal era with a mixture of success and failure. The successful national scale-up of prevention of mother-to-child transmission of HIV services with increasingly efficacious antiretroviral regimens has reduced the mother-to-child transmission rate dramatically; however, over the same period there appears to have been no progress in coverage of high-impact interventions for pneumonia and diarrhoea, which are now leading causes of under-5 mortality. SA embarked on a strategy to re-engineer the primary healthcare system in 2011, which included the creation of ward-based outreach teams consisting of community health workers (CHWs). In this article we argue that the proposed ratio of CHWs to population is too low for public health impact and that the role and scope of CHWs should be extended beyond giving of health information to include assessment and treatment of childhood illnesses (particularly diarrhoea and suspected pneumonia). Evidence and experience amply demonstrate that CHWs in sufficient density can have a rapid and positive impact on neonatal and young child mortality, especially when they are allowed to treat common acute conditions. SA's mediocre performance in child survival could be dramatically improved if there were more CHWs who were allowed to do more.

Background: This study examines socioeconomic inequality in children's health and factors that moderate this inequality. Socioeconomic measures include household wealth, maternal education and urban/rural area of residence. Moderating factors include reproductive behavior, access to health care, time, economic development, health expenditures and foreign aid., Methods: Data are taken from Demographic and Health Surveys conducted between 2003 and 2012 in 26 African countries., Results: Birth spacing, skilled birth attendants, economic development and greater per capita health expenditures benefit the children of disadvantaged mothers, but the wealthy benefit more from the services of a skilled birth attendant and from higher per capita expenditure on health., Conclusion: Some health behavior and policy changes would reduce social inequality, but the wealthy benefit more than the poor from provision of health services.

Background: In 2010, Ethiopia began scaling up the integrated community case management (iCCM) of childhood illness strategy throughout the country allowing health extension workers (HEWs) to treat children in rural health posts. After 2 years of iCCM scale up, utilization of HEWs remains low. Little is known about factors related to the use of health services in this setting. This research aimed to elicit perceptions and experiences of caregivers to better understand reasons for low utilization of iCCM services., Methods: A rapid ethnographic assessment was conducted in eight rural health post catchment areas in two zones: Jimma and West Hararghe. In total, 16 focus group discussions and 78 in-depth interviews were completed with mothers, fathers, HEWs and community health volunteers., Results: In spite of the HEW being a core component of iCCM, we found that the lack of availability of HEWs at the health post was one of the most common barriers to the utilization of iCCM services mentioned by caregivers. Financial and geographic challenges continue to influence caregiver decisions despite extension of free child health services in communities. Acceptability of HEWs was often low due to a perceived lack of sensitivity of HEWs and concerns about medicines given at the health post. Social networks acted both to facilitate and hinder use of HEWs. Many mothers stated a preference for using the health post, but some were unable to do so due to objections or alternative care-seeking preferences of gatekeepers, often mothers-in-law and husbands., Conclusion: Caregivers in Ethiopia face many challenges in using HEWs at the health post, potentially resulting in low demand for iCCM services. Efforts to minimize barriers to care seeking and to improve demand should be incorporated into the iCCM strategy in order to achieve reductions in child mortality and promote equity in access and child health outcomes., (© The Author 2015. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

As part of the "Grand Convergence: Aligning Technologies and Realities in Global Health" Collection, Cyril Engmann and colleagues discuss promising innovations that have the potential to move the RMNCH agenda forward.

Background: Health systems aim to narrow inequality in access to health care across socioeconomic groups and area of residency. However, in low-income countries, studies are lacking that systematically monitor and evaluate health programs with regard to their effect on specific inequalities. We aimed to measure changes in inequality in access to maternal and child health (MCH) interventions and the effect of Primary Health Care (PHC) facilities expansion on the inequality in access to care in Ethiopia., Methods: The Demographic and Health Survey datasets from Ethiopia (2005 and 2011) were used. We calculated changes in utilization of MCH interventions and child morbidity. Concentration and horizontal inequity indices were estimated. Decomposition analysis was used to calculate the contribution of each determinant to the concentration index., Results: Between 2005 and 2011, improvements in aggregate coverage have been observed for MCH interventions in Ethiopia. Wealth-related inequality has remained persistently high in all surveys. Socioeconomic factors were the main predictors of differences in maternal and child health services utilization and child health outcome. Utilization of primary care facilities for selected maternal and child health interventions have shown marked pro-poor improvement over the period 2005-2011., Conclusions: Our findings suggest that expansion of PHC facilities in Ethiopia might have an important role in narrowing the urban-rural and rich-poor gaps in health service utilization for selected MCH interventions.

Background and Objective: Emergency departments must have appropriate resources and equipment available to meet the unique needs of children. We assessed the availability of stakeholder-endorsed quality structure performance measures for pediatric emergency department patients., Methods: A survey of Child Health Corporation of America member hospitals was conducted. Six broad equipment groups were queried: general, monitoring, respiratory, vascular access, fracture-management, and specialized pediatric trays. Equipment availability was determined at the level of the individual item, 6 broad groups, and 44 equipment subgroups. The survey queried the availability of 8 protocol/procedure elements: method to identify age-based abnormal vital signs, patient-centered care advisory council, bronchiolitis evidence-based guideline, pediatric radiation dosing standards, suspected child abuse protocols, use of validated pediatric triage tool, and presence of nurse and physician pediatric coordinators., Results: Fifty-two percent (22/42) of sites completed the survey. Forty-one percent reported availability of all 113 recommended equipment items. Every hospital reported complete availability of equipment in 77% of the subgroups. The most common missing items were adult-sized lumbar puncture needles, hypothermia thermometers, and various sizes of laryngeal mask airways. Regarding the protocol/procedure elements, a method to identify age-based abnormal vital signs, pediatric radiation dosing standard, and nurse and physician pediatric coordinators were present in 100%. Ninety-five percent used a validated triage tool and had suspected child abuse protocols., Conclusions: Presence of necessary pediatric emergency equipment is better in the surveyed hospitals than in prior reports. Most responding hospitals have important protocol/procedures in place. These data may provide benchmarks for optimal care.

The health home program established under the Affordable Care Act (2010) is derived from the medical home concept originated by the American Academy of Pediatrics in 1968 to provide a care delivery model for children with special health care needs. As applied to behavioral health, health homes or medical homes have become increasingly adult-focused models, with a primary goal of coordinating physical and behavioral health care. For children and youth with serious emotional disorders, health homes must go beyond physical and behavioral health care to connect with other child-focused sectors, such as education, child welfare, and juvenile justice. Each of these systems have a significant role in helping children meet health and developmental goals, and should be included in integrated approaches to care for children and youth. Health homes for young people should incorporate a continuum of care from health promotion to the prevention and treatment of disorders. The challenge for child- and youth-focused health homes is to integrate effective services and supports into the settings where young people naturally exist, drawing on the best evidence from mental health, physical medicine, and other fields. What may be needed is not a health home as currently conceptualized for adults, nor a traditional medical home, but a family- and child-centered coordinated care and support delivery system supported by health homes or other arrangements. This article sets out a health home framework for children and youth with serious mental health conditions and their families, examining infrastructure and service delivery issues., ((c) 2016 APA, all rights reserved).)

Objectives: A community based approach before, during and after child birth has been proven effective address the burden of maternal, neonatal and child morbidity and mortality in the low and middle income countries. We aimed to examine the overall change in maternal and newborn health outcomes due the "Improved Maternal Newborn and Child Survival" (IMNCS) project, which was implemented by BRAC in rural communities of Bangladesh., Methods: The intervention was implemented in four districts for duration of 5-years, while two districts served as comparison areas. The intervention was delivered by community health workers who were trained on essential maternal, neonatal and child health care services. A baseline survey was conducted in 2008 among 7, 200 women with pregnancy outcome in last year or having a currently alive child of 12-59 months. A follow-up survey was administered in 2012-13 among 4, 800 women of similar characteristics in the same villages., Findings: We observed significant improvements in maternal and essential newborn care in intervention areas over time, especially in health care seeking behaviors. The proportion of births taking place at home declined in the intervention districts from 84.3% at baseline to 71.2% at end line (P<0.001). Proportion of deliveries with skilled attendant was higher in intervention districts (28%) compared to comparison districts (27.4%). The number of deliveries was almost doubled at public sector facility comparing with baseline (P<0.001). Significant improvement was also observed in healthy cord care practice, delayed bathing of the new-born and reduction of infant mortality in intervention districts compared to that of comparison districts., Conclusions: This study demonstrates that community-based efforts offer encouraging evidence and value for combining maternal, neonatal and child health care package. This approach might be considered at larger scale in similar settings with limited resources.

Objective: Access to genetic counseling is increasingly important to guide families' and clinicians' decision making, yet there is limited research on accessibility and affordability of counseling for families with children with special health care needs (CSHCN). Our study's objectives were to measure changes in unmet need for genetic counseling for CSHCN from 2001 to 2010 and to characterize child, family, and health system factors associated with unmet need., Methods: We used parent-reported data from the 2001, 2005-2006, and 2009-2010 National Survey of Children With Special Health Care Needs. We used a logistic regression model to measure the impact of survey year, child (sex, age, severity of health condition), family (primary language, household income, insurance, financial problems related to cost of CSHCN's health care), and health system factors (region, genetic counselors per capita, having a usual source of care) on access to genetic counseling., Results: Unmet need for genetic counseling increased significantly in 2009-2010 compared to 2001 (odds ratio 1.89; 95% confidence interval [CI] 1.44-2.47). Being older (adjusted odds ratio [aOR] 1.04; 95% CI 1.02-1.06), having severe health limitations (aOR 1.72; 95% CI 1.16-2.58), being uninsured (aOR 3.56; 95% CI 2.16-5.87), and having family financial problems due to health care costs (aOR 1.90; 95% CI 1.52-2.38) were significantly associated with greater unmet need for genetic counseling. Having a usual source of care was associated with decreased unmet need (aOR 0.55; 95% CI 0.37-0.83)., Conclusions: Unmet need for genetic counseling has increased over the past 12 years. Uninsurance and financial problems related to health care costs were the largest drivers of unmet need over time., (Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Children with life-limiting and disabling conditions are surviving longer than previously, and many require palliative and supportive care, usually at home. Home-based care can put family life under considerable strain, as parents care for their child's complex, often unpredictable, continuing care needs. Rainbow Trust Children's Charity aims to bridge gaps in services for children with life-threatening or terminal conditions by providing family support workers (FSWs). The study used a range of methods (surveys, interviews and ethnographic observation) approach to explore key aspects of the work of the FSWs. The target population for the surveys was families with a child having complex, life-threatening or terminal conditions receiving care from FSWs. The participants included 55 families (12 bereaved) and 39 children aged 2-18 years. Thematic analysis revealed how the FSWs became a presence in families' lives in three main ways: (1) encompassing and embracing families through supporting needs and promoting resilience; (2) befriending and bonding through developing knowledge, trusting relationships and a sense of closeness; and (3) accompanying and enduring by 'being with' families in different settings, situations and crises and by enduring alongside the families. The study demonstrated the fundamental importance of workers who are able to provide aspects of support that is usually not provided by other services., (© The Author(s) 2013.)

Children with life limiting conditions and their families have complex needs. Evaluations must consider their views and perspectives to ensure care is relevant, appropriate and acceptable. We consulted with children, young people, their parents and local professionals to gain a more informed picture of issues affecting them prior to preparing a bid to evaluate services in the area. Multiple methods included focus groups, face-to-face and telephone interviews and participatory activities. Recordings and products from activities were analysed for content to identify areas of relevance and concern. An overarching theme from parents was 'Why does it happen like this?' Services did not seem designed to meet their needs. Whilst children and young people expressed ideas related to quality of environment, services and social life, professionals focused on ways of meeting the families' needs. The theme that linked families' concerns with those of professionals was 'assessing individual needs'. Two questions to be addressed by the evaluation are (1) to what extent are services designed to meet the needs of children and families and (2) to what extent are children, young people and their families consulted about what they need? Consultations with families and service providers encouraged us to continue their involvement as partners in the evaluation., (© The Author(s) 2013.)

Background: We assessed the prevalence of dental disease among U.S. children and adolescents aged 6-17 years, as well as the impact of unmet dental needs on school absenteeism because of illness/injury within the past 12 months., Methods: Data were from the 2011/2012 National Survey of Children's Health (n=65,680). Unmet dental need was defined as lack of access to appropriate and timely preventive or therapeutic dental healthcare when needed within the past 12 months. The impact of unmet dental needs on school absenteeism was measured using a multivariate generalized linear model with Poisson probability distribution (p<0.05)., Results: Within the past 12 months, 21.8% (10.8 million) of all U.S. children and adolescents aged 6-17 years had "a toothache, decayed teeth, or unfilled cavities." Of all U.S. children and adolescents aged 6-17 years, 15.8% (7.8 million) reported any unmet dental need (i.e., preventive and/or therapeutic dental need) within the past 12 months. The mean number of days of school absence because of illness/injury was higher among students with an unmet therapeutic dental need in the presence of a dental condition compared to those reporting no unmet dental need (β=0.25; p<0.001)., Conclusions: Enhanced and sustained efforts are needed to increase access to dental services among underserved U.S. children and adolescents., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Children in many areas of New Zealand have poor health indices; statistics indicate health inequalities. Existing international indicators of child health currently take little account of local context. There are few composite indicators of how child health services are integrated at a community level. This study aimed to explore what local people consider would be useful indicators of better child health. Data for this qualitative study were collected via 24 individual interviews and two focus groups in a rural area of New Zealand. A total of 13 in-depth interviews were conducted with parents/families of small children. Participants were asked about wide-ranging aspects of child health. Also, 11 interviews and two focus groups were conducted with front line health professionals/stakeholders. Key themes from the content thematic analysis: include child health should be measured in multidimensional ways; essential interdependence of family-child health; universal access to culturally appropriate care, free primary care services and parenting education and support is needed; and there is a lack of integration and communication between health, education and social services. There is an important need to measure and monitor communication/integration across existing health, education and social services, provide better parenting support and health education and improve access to culturally appropriate primary care., (© The Author(s) 2013.)

It is not inconceivable that by 2035 the substantial gaps in child health across the Pacific can close significantly. Currently, Australia and New Zealand have child mortality rates of 5 and 6 per 1000 live births, respectively, while Pacific island developing nations have under 5 mortality rates ranging from 13 to 16 (Vanuatu, Fiji and Tonga) to 47 and 58 per 1000 live births (Kiribati and Papua New Guinea, respectively). However, these Pacific child mortality rates are falling, by an average of 1.4% per year since 1990, and more rapidly (1.9% per year) since 2000. Based on progress elsewhere, there is a need to (i) define the specific things needed to close the gaps in child health; (ii) be far more ambitious and hopeful than ever before; and (iii) form a new regional compact based on solidarity and interdependence., (© 2015 The Authors. Journal of Paediatrics and Child Health published by Wiley Publishing Asia Pty Ltd on behalf of Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

This article focuses on the health of women and girls, and the role of addressing gender inequalities experienced by women and girls. The health of both males and females is influenced by sex, or biological factors, and gender, or socially constructed influences, including gender differences in the distribution and impact of social determinants of health, access to health promoting resources, health behaviors and gender discourse, and the ways in which health systems are organized and financed, and how they deliver care. Various strategies to address the health of women and girls have been developed at intergovernmental, regional, and national level, and by international nongovernmental organizations. These include vertical programs which aim to target specific health risks and deliver services to meet women and girl's needs, and more cross-cutting approaches which aim at "gender" policy making. Much of this work has developed following the adoption of gender mainstreaming principles across different policy arenas and scales of policy making, and this article reviews some of these strategies and the evidence for their success, before concluding with a consideration of future directions in global policy., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objectives: To determine if clinicians and staff from 21 diverse primary care practice settings could implement the 2008 Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd edition recommendations, at the 9- and 24-month preventive services visits., Methods: Twenty-two practice settings from 15 states were selected from 51 applicants to participate in the Preventive Services Improvement Project (PreSIP). Practices participated in a 9-month modified Breakthrough Series Collaborative from January to November 2011. Outcome measures reflect whether the 17 components of Bright Futures recommendations were performed at the 9- and 24-month visits for at least 85% of visits. Additional measures identified which office systems were in place before and after the collaborative., Results: There was a statistically significant increase for all 17 measures. Overall participating practices achieved an 85% completion rate for the preventive services measures except for discussion of parental strengths, which was reported in 70% of the charts. The preventive services score, a summary score for all the chart audit measures, increased significantly for both the 9-month (7 measures) and 24-month visits (8 measures)., Conclusions: Clinicians and staff from various practice settings were able to implement the majority of the Bright Futures recommended preventive services at the 9- and 24-month visits at a high level after participation in a 9-month modified Breakthrough Series collaborative., (Copyright © 2015 by the American Academy of Pediatrics.)

Background: Infants and toddlers with developmental difficulties represent a heterogeneous group who often receives early intervention (EI). Notable population heterogeneity exists and complicates unmet need and effectiveness research. However, a mix of relatively homogeneous clinically policy relevant 'subgroups' may create the apparent heterogeneity. To date, methodological challenges have impeded identifying these potential groups and their policy-relevance., Methods: From the 2005-2006 National Survey of Children with Special Health Care Needs, we derived a sample (n = 965) of infants and toddlers with parent-reported developmental difficulties. We used latent class analysis (LCA) to identify subgroups of developmental vulnerability based upon functional, social and biological characteristics that would make children eligible for EI. Mixture modelling estimated the likelihood of each subgroup receiving parent-reported EI, controlling for race/ethnicity, child's age, and state of residence., Results: LCA identified four distinct subgroups of developmental vulnerability: developmental disability (Group 1), mild developmental delay (Group 2), socially at risk with behaviour problems (Group 3), and socially at risk with functional vision difficulties (Group 4). Black, non-Hispanic children are significantly more likely than their white counterparts to be in Group 3 (β = 1.52, P = 0.001) or group 4 (β = 1.83, P < 0.001). Compared with children with a mild developmental delay (Group 2), children in group 1 (β = -0.61, P < 0.001), group 3 (β = -0.47, P = 0.001) and group 4 (β = -0.38, P = 0.009) are significantly less likely to receive EI., Conclusions: Racial and ethnic differences exist with regard to membership in developmental vulnerability subgroups. Observed inconsistencies in access to EI suggest the need for improved surveillance, referral and outreach., (© 2012 John Wiley & Sons Ltd.)

If children are to be protected from HIV, the expansion of PMTCT programs must be complemented by increased provision of paediatric treatment. This is expensive, yet there are humanitarian, equity and children's rights arguments to justify the prioritization of treating HIV-infected children. In the context of limited budgets, inefficiencies cost lives, either through lower coverage or less effective services. With the goal of informing the design and expansion of efficient paediatric treatment programs able to utilize to greatest effect the available resources allocated to the treatment of HIV-infected children, this article reviews what is known about cost drivers in paediatric HIV interventions, and makes suggestions for improving efficiency in paediatric HIV programming. High-impact interventions known to deliver disproportional returns on investment are highlighted and targeted for immediate scale-up. Progress will carry a cost - increased funding, as well as additional data on intervention costs and outcomes, will be required if universal access of HIV-infected children to treatment is to be achieved and sustained.