Search

Introduction In 2013, reviews of effective nutrition interventions estimated that scaling-up a set of proven nutrition-specific interventions could reduce stunting globally by 20% and reduce child mortality by 15%. (1) [...], Objective To investigate coverage and equity of India's Integrated Child Development Services programme across the continuum of care from pregnancy to early childhood, before and after the programme was expanded to provide universal access. Methods The programme offers nutrition and health services to pregnant and lactating mothers and young children. We used data from nationally representative surveys in 2005-2006 and 2015-2016, including 36 850 mother-child pairs in 2006 and 190 804 in 2016. We assessed changes in the equity of use of programme services by socioeconomic quintile, caste, education and rural or urban residence. We used regression models to investigate the determinants of programme use. Findings The mean proportion of respondents using programme services increased between 2006 and 2016, from 9.6% to 37.9% for supplementary food, 3.2% to 21.0% for health and nutrition education, 4.5% to 28% for health check-ups and 10.4% to 24.2% for child-specific services (e.g. immunization, growth monitoring). Wealth, maternal education and caste showed the largest positive associations with use of services. However, expansion in service use varied at the sub-national level. Although overall use had improved and reached marginalized groups such as disadvantaged castes and tribes, the poorest quintiles of the population were still left behind, especially in the largest states that carry the highest burden of undernutrition. Conclusion India's policy reforms have increased coverage of the programme at the national level, including for marginalized groups. With further scaling-up, the programme needs to focus on reaching households from the lowest socioeconomic strata and women with low schooling levels. Objectif Etudier la couverture et l'equite du programme indien de services integres pour le developpement de l'enfant (Integrated Child Development Services) tout au long du continuum de soins, depuis la grossesse jusqu'a la petite enfance, avant et apres l'extension du programme visant a garantir un acces universel. Methodes Ce programme propose des services de nutrition et de sante aux femmes enceintes, aux femmes qui allaitent et aux jeunes enfants. Nous avons utilise des donnees provenant d'enquetes nationalement representatives, realisees en 2005-2006 et en 2015-2016, qui ont implique 36 850 paires mere-enfant en 2006 et 190 804 paires mereenfant en 2016. Nous avons evalue les changements en matiere d'equite dans l'utilisation de ces services par quintile socioeconomique, caste, niveau d'education et residence rurale ou urbaine. Nous avons utilise des modeles de regression pour etudier les determinants de l'utilisation du programme. Resultats La proportion moyenne de personnes interrogees utilisant les services du programme a augmente entre 2006 et 2016, en passant de 9,6% a 37,9% pour la fourniture de supplements alimentaires, de 3,2% a 21,0% pour les services d'education sur la sante et la nutrition, de 4,5% a 28% pour les bilans de sante et de 10,4% a 24,2% pour les services specifiques a l'enfant (ex.: vaccination, surveillance de la croissance). Le niveau de revenus, le niveau d'education de la mere et la caste correspondent aux associations les plus largement positives avec l'utilisation des services. Neanmoins, l'augmentation de l'utilisation des services a varie au niveau sous-national. Meme si l'utilisation generale a augmente et que les services ont atteint des groupes marginalises, tels que les castes et les tribus les plus defavorisees, les quintiles les plus pauvres de la population sont restes laisses pour compte, notamment dans les plus grands etats, qui sont les plus lourdement frappes par la denutrition. Conclusion En Inde, les reformes des politiques ont permis d'obtenir une meilleure couverture au niveau national, y compris pour les groupes marginalises. Pour ses prochaines extensions, le programme devra cibler les menages appartenant aux couches socioeconomiques les plus pauvres et les femmes ayant un niveau d'education bas. Objetivo Investigar la cobertura y la equidad del Programa de servicios integrados de desarrollo infantil de la India a traves de la atencion continua desde el embarazo hasta la infancia temprana, antes y despues de que el programa se ampliara para proporcionar acceso universal. Metodos El programa ofrece servicios de nutricion y salud a madres embarazadas y lactantes y a ninos pequenos. Se utilizaron datos de encuestas representativas a nivel nacional de 2005-2006 y 2015-2016, incluidas 36 850 parejas de madres e hijos en 2006 y 190 804 en 2016. Se evaluaron los cambios en la equidad de uso de los servicios del programa por quintil socioeconomico, casta, educacion y residencia rural o urbana. Se utilizaron modelos de regresion para investigar los determinantes del uso del programa. Resultados La proporcion media de encuestados que utilizan los servicios del programa aumento entre 2006 y 2016, del 9,6 % al 37,9 % en el caso de los alimentos suplementarios, del 3,2 % al 21,0 % en el de la educacion sanitaria y nutricional, del 4,5 % al 28 % en el de los reconocimientos medicos y del 10,4 % al 24,2 % en el de los servicios especificos para ninos (por ejemplo, inmunizacion o vigilancia del crecimiento). La riqueza, la educacion materna y la casta mostraron las mayores asociaciones positivas con el uso de los servicios. Sin embargo, la expansion del uso de servicios vario a nivel subnacional. Aunque el uso general ha mejorado y ha llegado a grupos marginados como las castas y tribus desfavorecidas, los quintiles mas pobres de la poblacion siguen quedando rezagados, especialmente en los estados mas grandes que soportan la mayor carga de desnutricion. Conclusion Las reformas politicas de la India han aumentado la cobertura del programa a nivel nacional, incluso para los grupos marginados. Con una mayor ampliacion, el programa debe centrarse en llegar a los hogares de los estratos socioeconomicos mas bajos y a las mujeres con bajos niveles de escolaridad.

Specialty care is important for many children with chronic conditions, but access to such care may be constrained within managed care environments. (1) The use of primary care providers (PCPs) [...], Background. Limited information is available about managed care organization (MCO) characteristics that influence outpatient physician specialist use among children with chronic conditions. Objective. To examine the association between MCO characteristics and outpatient physician specialist use among children with chronic conditions who were receiving care in MCOs in which primary care providers (PCPs) served as gatekeepers for referrals and who were publicly insured. Design and Methods. A total of 2333 children who had been diagnosed with a chronic condition and had functional limitations, an increased need for or use of health care services beyond what children normally use, and/or dependence on medications or home medical equipment were included in the study. The odds of an outpatient physician specialist visit 1 year after study entry were examined as a function of child health and sociodemographic characteristics, MCO characteristics, the child's prior specialty care use, and provider availability in the MCO service delivery area. Results. Children cared for in MCOs with lower percentages of PCPs paid on a fee-for-service basis (odds ratio: 0.95; 95% confidence interval: 0.92-0.98), with higher percentages of pediatricians in the PCP network (odds ratio: 1.17; 95% confidence interval: 1.07-1.29), and offering financial incentives for meeting quality of care standards (odds ratio: 1.71; 95% confidence interval: 1.28-2.29) had greater odds of outpatient physician specialist visits. Black children had odds of specialty care that were approximately one half those of white children. Children with prior physician specialist use were 52% more likely to have a physician specialist visit in the year after study entry. The children's diagnoses and condition consequences were not related significantly to the odds of a specialty visit. Conclusions. Specific MCO characteristics were associated with greater specialty care use among a group of low-income children with chronic conditions. Such information should be used to improve the structure of managed care arrangements for these vulnerable children. Pediatrics 2005;115:1547; children, chronic conditions, pediatric specialty care use, managed care. ABBREVIATIONS. MCO, managed care organization; PCP, primary care provider; SCHIP, State Children's Health Insurance Program; FPL, federal poverty level; ICD-9, International Classification of Diseases, Ninth Revision; ADD, attention-deficit disorder; ADHD, attention-deficit/hyperactivity disorder; QuICCC, Questionnaire for Identifying Children With Chronic Conditions.

Collaboration, partnership and interagency working are terms frequently employed to highlight the need for providers of services and families to work together to meet the needs of the individual child. [...]

Objectives The multi-country evaluation of Integrated Management of Childhood Illness (IMCI) effectiveness, cost and impact (MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. MCE studies are under way in Bangladesh, Brazil, Peru, Uganda and the United Republic of Tanzania. The objective of this analysis from the Bangladesh MCE study was to describe the quality of care delivered to sick children under 5 years old in first-level government health facilities, to inform government planning of child health programmes. Methods Generic MCE Health Facility Survey tools were adapted, translated and pre-tested. Medical doctors trained in IMCI and these tools conducted the survey in all 19 health facilities in the study areas. The data were collected using observations, exit interviews, inventories and interviews with facility providers. Findings Few of the sick children seeking care at these facilities were fully assessed or correctly treated, and almost none of their caregivers were advised on how to continue the care of the child at home. Over one-third of the sick children whose care was observed were managed by lower-level workers who were significantly more likely than higher-level workers to classify the sick child correctly and to provide correct information on home care to the caregiver. Conclusion These results demonstrate an urgent need for interventions to improve the quality of care provided for sick children in first-level facilities in Bangladesh, and suggest that including lower-level workers as targets for IMCI case-management training may be beneficial. The findings suggest that the IMCI strategy offers a promising set of interventions to address the child health service problems in Bangladesh. Keywords Child health services/standards; Primary health care; Quality of health care; Quality indicators, Health care; Health care surveys; Child, Preschool; Bangladesh (source: MeSH, NLM)., Introduction Each year over 10 million children in low- and middle-income countries die before their fifth birthday (1, 2). About half of these deaths are due to pneumonia, diarrhoea, malaria [...]

ABSTRACT. Objective. Children are frequently perceived to be healthy, low-risk individuals with a majority of clinical services devoted to health maintenance and preventive clinical services. However, a subset of children have unique needs that require specialized care to achieve optimal health outcomes. The purpose of this research was to use survey tools that have been developed to identify children with special health care needs (CSHCN) to measure prevalence and resource needs of these children in the military health system (MHS). Methods. The US Department of Defense manages the MHS, which is one of the largest integrated health care systems in the world and provides care to almost 2 000 000 children. We incorporated the CSHCN survey screener and assessment questions into the annual health care survey of beneficiaries who are eligible for benefits within the MHS. In addition, we used claims information available from inpatient and outpatient services. We used parent reports from the survey to estimate the prevalence of CSHCN. Incorporating claims data and restricting our analyses to those who were enrolled continuously in a military health maintenance organization (TRICARE Prime), we described utilization of different types of health care resources and compared CSHCN with their healthy counterparts. Finally, we examined alternative types of special needs and performed regression analyses to identify the major determinants of health needs and resource utilization to guide system management and policy development. Results. CSHCN compose 23% of the TRICARE Prime enrollees who are younger than 18 years and whose parents responded to the survey. The needs of a majority of these children consist of prescription medications and services targeting medical, mental health, and educational needs. CSHCN experience 5 times as many admissions and 10 times as many days in hospitals compared with children without special needs. CSHCN are responsible for nearly half of outpatient visits for enrolled children and more than three quarters of inpatient days. Service utilization varies dramatically by type of special need and other demographic variables. Conclusion. CSHCN represent a major challenge to organized systems of care and our society. Because they represent a group of children who are particularly at risk with potential for improved health outcomes, efforts to improve quality, coordinate care, and optimize efficiency should focus on this target population. children with special health care needs, service use, CSHCN screener, military health system., ABBREVIATIONS. DoD, US Department of Defense; MHS, military health system; HCSDB, Health Care Survey of DoD Beneficiaries; DEERS, Defense Eligibility and Enrollment Reporting System; SIDR, standard inpatient data record; SADR, [...]

ABBREVIATIONS. AGPE, anticipatory guidance and education; FCC, family-centered care; FA, family psychosocial risks; SDA, smoking and drug and alcohol use; APP, American Academy of Pediatrics; PHDS, Promoting Healthy Development Survey; [...], Objective. To generate a national picture of performance in the area of preventive and developmental services for children aged 4 to 35 months using 4 composite quality measures in the areas of 1) anticipatory guidance and parental education, 2) screening for family psychosocial risks, 3) screening for smoking and drug and alcohol use in the home, and 4) provision of family-centered care. Methods. Data from the National Survey on Early Childhood Health (N = 2068) were used to calculate the 4 composite performance measures, which, taken together, represent 23 topics included in the American Academy of Pediatrics health supervision guidelines. The reliability and degree of redundancy within and across these 4 measures were evaluated. Four methods for scoring these measures were used. Quality scores for subgroups of children were calculated, and logistic regression analysis was performed to examine the association of demographic, health, and health system variables with receiving recommended care. Results. Regardless of the scoring method used, performance is highest in areas of family-centered care and screening for smoking and drug and alcohol use in the home. Performance is lowest in the areas of anticipatory guidance and education and assessment for family psychosocial risks. Using a scoring method that takes into account parent preferences for guidance and beliefs about discussing psychosocial topics, composite quality measure scores ranged from 13.5% to 59.6% of parents of young children receiving recommended care. Overall, 94.0% of parents reported I or more unmet needs for parenting guidance, education, and screening by pediatric clinician(s) in 1 or more of the content of care areas evaluated. Uninsured children and children aged 18 to 35 months are disproportionately represented among the 15.3% of children whose parents indicated an unmet need in each of the 4 areas of care. Although the reliability of each composite measure was high, no single item in any composite was highly correlated with the remaining combined items. Performance on any 1 composite measure for a child was only somewhat predictive of performance for the other measures. There are significant variations in performance on the basis of child age, race, insurance status, maternal education, marital status, and parent language as well as other factors. Conclusions. National results using 4 complementary composite quality measures confirm the need for improving the quality of preventive and developmental services for young children in the United States. The 4 measures identify areas of care and subgroups of children for whom improvements in quality are most needed. The measures provide a parsimonious yet comprehensive assessment across distinct health supervision topics and 4 essential aspects of preventive and developmental services. Until valid measures of outcomes of preventive and developmental services are identified or 1 single process of care measure is shown to be highly predictive of these outcomes, assessing multiple aspects of recommended care will be necessary to assess performance of health care providers or systems of care. Pediatrics 2004;113:1973-1983; quality of care, health supervision, quality measures.

The perception and barriers to dental care for the children with special needs in Alabama are discussed. The studies show that one-third of the children do not have access to dental care, and this problem can be improved by increased participation in the Medicaid program and education about prevention of oral disease in children with special needs at an early age.

ABBREVIATIONS. EMR, electronic medical record; RR, relative risk; CI, confidence interval; PPCC, pediatric primary care center; ARCH, Automated Record for Child Health; SEF, structured encounter form; RHCM, routine health care [...], Objective. To evaluate the quality of pediatric primary care, including preventive services, before and after the introduction of an electronic medical record (EMR) developed for use in an urban pediatric primary care center. Methods. A pre-postintervention analysis was used in the study. The intervention was a pediatric EMR. Routine health care maintenance visits for children Results. A total of 235 paper-based visits and 986 computer-based visits met study criteria. Twelve clinicians (all attendings or nurse practitioners) contributed an average of 19.4 paper-based visits (range: 5-39) and 7 of these clinicians contributed an average of 141 computer-based visits each (range: 61-213). Computer-based clinicians were significantly more likely to address a variety of routine health care maintenance topics including: diet (relative risk [RR]: 1.09), sleep (RR: 1.46), at least 1 psychosocial issue (RR: 1.42), smoking in the home (RR: 15.68), lead risk assessment (RR: 106.54), exposure to domestic or community violence (RR: 35.19), guns in the home (RR: 58.11), behavioral or social developmental milestones (RR: 2.49), infant sleep position (RR: 9.29), breastfeeding (RR: 1.99), poison control (RR: 3.82), and child safety (RR: 1.29). Trends toward improved lead exposure, vision, and hearing screening were seen; however, differences were not significant. Users of the system reported that its use had improved the overall quality of care delivered, was well-accepted by families, and improved guidance quality; however, 5 of 7 users reported that eye-to-eye contact with patients was reduced, and 4 of 7 reported that use of the system increased the duration of visits (mean: 9.3 minutes longer). All users recommended continued use of the system. Conclusion. Use of the EMR in this study was associated with improved quality of care. This experience suggests that EMRs can be successfully used in busy urban pediatric primary care centers and, as recommended by the Institute of Medicine, must play a central role in the redesign of the US health care system. Pediatrics 2003;111:626-632; electronic medical record, computer-based, primary care, quality, child health services.

Adolescent drug use in the United States remains the highest in the industrialized world. Fortunately there have been significant advances in developing effective prevention programs for adolescent drug use. An important issue in evaluating such programs is that the self-report surveys have adequate psychometric properties and assess constructs targeted by an intervention. A questionnaire focusing on knowledge and drug-related measures was developed to evaluate the research-based Life Skills Training drug prevention intervention. The questionnaire showed good internal reliability, detected change from pretest to posttest, and was brief and easy to complete by 45 middle-school students.

Objective: To conceptualize the underlying causes of the medical neglect of children in a developing country and to provide suggestions for the management of neglect by pediatricians. Methods: A case history of a 4-year-old boy from Turkey with neglect of the required treatment for acute lymphoblastic leukemia is used to examine the causes and management of medical neglect. Results: Although epidemiological studies on child neglect are lacking, this case exemplifies how in developing countries, reasons for neglect or non-compliance with medical recommendations and the roles and actions taken by the health care and the social service systems may differ from western populations. Common to both western and developing countries, the characteristics of the child, family, and society may be reasons for medical neglect. However, cultural fatalistic beliefs profoundly present in the developing world may also contribute to the medical neglect of a child. Identification of the neglect, a comprehensive, multidisciplinary assessment emphasizing the strengths within the family and the society, and the determination of the pediatric team to act in the best interest of the child may result in resolution of the neglect even in circumstances where resources within systems are not sufficient. Conclusions: In developing countries, increased emphasis on child neglect, its prompt recognition and management within the pediatric profession as well as at a health care and social service system levels are needed to address this prevalent and potentially fatal child health problem. Keywords: Child neglect; Developing country

Byline: Arden Handler (1), Holly Grason (2), Marjory Ruderman (2), Michele Issel (1), Bernard Turnock (1) Keywords: performance measurement; capacity assessment; maternal and child health; state and local health agencies Abstract: Objectives: To understand the similarities, differences, and relationships between three tools for performance and capacity assessment currently available for Maternal and Child Health (MCH) programs and for state and local health agencies. Methods: Three tools for performance and capacity assessment currently available for Maternal and Child Health (MCH) programs and for state and local health agencies, the Title V MCH Block Grant Performance and Outcome Measures (Title V "24"), CAST-5, and the National Public Health Performance Standards Program (NPHPSP) were compared using two metrics, a conceptual model of the public health system, and a set of attributes related to the use of the instruments. Results: Both CAST-5 and the NPHPSP are focused on the capacity and key processes (10 Essential Public Health Services) of the public health system, although CAST-5 is intended for capacity assessment and the NPHPSP is intended for performance measurement. The Title V "24" tool is also intended for performance measurement however, its focus is on the outputs and outcomes of the health system. The Title V "24" tool is the only one of the three that is mandatory, and the only one whose results at the current time can be used to compare across entities. In addition, both the Title V "24" and the NPHPSP include explicit standards, while CAST-5 does not specify explicit standards against which to compare findings. Conclusions: While there are various tools available to MCH practitioners for capacity assessment and performance measurement, knowing how the tools relate to each other, and their defining characteristics, should lead to more effective and productive use. Author Affiliation: (1) Community Health Sciences, University of Illinois School of Public Health, Chicago, Illinois (2) Women's and Children's Health Policy Center, Johns Hopkins University School of Public Health, Baltimore, Maryland Article History: Registration Date: 04/10/2004

A focused ethnographic study in an urban Latino community in the western United States describes Mexican-origin mothers' experiences obtaining and using health services for their children. Repeated interviews with mothers, participant observation, and children's medical records composed the datasources. Qualitative findings suggest access to health care begins in the household, where women negotiate a working diagnosis for the children's illness with family members and coalesce support for health care seeking. Immigrant mothers described more barriers to children's health care than more acculturated mothers. Quantitative analyses of medical records supported this finding, with children of the least acculturated mothers demonstrating fewer well-child visits, increased emergent visits, and lower levels of immunization completeness. The results suggest health care providers can better meet the needs of Latino families with children by offering better explanations about children's diagnoses and treatment plans and demonstrating personalismo, or a friendly, kind, and social approach to care.

Several child health care programmes, though often well conceived, are poorly implemented at field level and focus primarily on quantitative achievements to the neglect of quality of care. This paper presents a quality of care (QOC) framework for child health programmes from the perspectives of the management system of an organization and the provider client interface at point of service delivery. The paper subsequently describes the application of qualitative and quantitative research tools drawn from the social sciences and health sciences for planning and evaluating quality of care. An integrated and complementary use of these tools is recommended. It is suggested that minimum standards, which are region specific, be articulated for quality maintenance in child health programmes. These standards may be upgraded as quality improves. Finally, the challenges which a partnership of the health and social sciences may have to take up are discussed. These include advocacy for prioritization of QOC in child health programmes, facilitating an environment which supports quality of care, promoting inter-disciplinary action research, training students in social science research in universities and research organizations, documenting success stories. Key words - quality of care, child health programmes, developing countries

Keywords: Assessment; maternal and child health; data utilization skills development Abstract: Objectives: Since the publication of the Future of Public Health, a high priority has been placed on the development of the assessment capacity in public health programs. Method: Key informant interviews were conducted by telephone with selected program personnel of state Maternal and Child Health and Children with Special Health Care Needs programs in ten southeastern states to determine perceived deficiencies in skills needed to carry out assessments. Results: We found that professional staff perceived that several fundamental assessment skills were available in their units, including collecting secondary data, and creating interagency groups and frameworks for assessment. In contrast, program staff perceived that their units did not have adequate skills to carry out many other critical assessment tasks, including the ability to analyze data using descriptive statistics. Conclusions: Our findings support the argument that more funds and staff resources must be devoted to the development of analytic skills, and to ensuring that consistent application of these skills is reinforced. Article History: Registration Date: 23/10/2004

Every community has children placed in the out-of-home care system. Despite a high prevalence of health, mental health, and developmental morbidity in children in care, most child welfare agencies have not provided adequate diagnostic and therapeutic services for these children. A comprehensive, multidisciplinary clinic for children in out-of-home care involving pediatrics, child psychology, nursing, child development, and child welfare is described. Profiles of the health, mental health, and developmental status of the children in out-of-home care are also presented.

The context of the Japanese health care setting shaped Japanese women's roles as the major and solo caretakers of their ill children, which caused them to be removed from the family unit during the children's illnesses. The mothers became sentinels and tried to protect their children from unnecessary physical and psychological distress and agony in the hospital context. Some of them comforted their children in the home-care context once their children reached the point where no other treatment could help. At the same time, they tried to establish effective relationships with health professionals, especially physicians. One third of the mothers gave the initiative to the physician, but almost half of the mothers shared the initiative to some degree with physicians on an equal or dominant-subordinate basis. Whether the mothers trusted the physicians did not relate to whether they shared the initiative or not, but was a primary factor in deciding whether to change hospitals. The mothers became monitors and advocates of their children during treatment, at first choosing to adapt to their subordinate position in the hospital, but becoming more assertive when they felt their children may be seriously harmed. Key words - mothers, health care system, doctor - patient relationship, crisis management, terminal illness

Culturally competent outcome evaluation of systems of personal care for children with emotional disorders shows that culturally competent programs are both cost-effective and clinically effective. Culturally competent systems of care take the effect of cultural diversity into account and deliver services in accordance with children's culture-specific needs. An outcome evaluation study involves population indicators and outcome indicators such as race, and functional change, respectively. This approach addresses cultural differences without injuring the interests of minorities.

A comparison between two family based treatments shows that individualized care treatment yields better results than non-individualized treatment for children with emotional disturbances. Children referred to foster care either in Family Centered Intensive Case Management (FCICM) or Family Based Treatment (FBT) reveal that subjects in the former exhibit reduced symptoms. They also indicate significant improvement in behavior, emotions and performance as compared to those in FBT. Positive results in terms of behavior management skills and family strengths are seen in the parents.

This paper examines the potential effects of user fees on the demand for child health care across income groups. A mixed/conditional logit model of provider choice is estimated using national data from the Philippines. The model explicitly allows for price elasticity to be dependent upon income. The results intricate that price plays a significant role in the demand for child health care and that medical care demand for poorer children is substantially more price sensitive than it is for richer children. The notion that user fees are regressive is therefore supported. Key words - demand function, price elasticity, user fees, Philippines' health research

Financial incentives in promoting childhood immunization can be cost effective. The success of such an approach as employed by Northern Ireland and Austria is informative. Equity and efficiency considerations support government involvement in the program. Studies show that there is a strong demand for childhood immunization and, although the US spends more per capita on medical care, it ignores the need for childhood immunization.

Much of child illness in developing countries can be explained by what have been called, 'proximate determinants,' principally infant feeding practices and preventive and curative care. During previous field research in a small village in Yemen the author observed that despite the uniformly unhealthy environment, a minority of the families carried most of the burden of child illness and death. This study was carried out to document that observation, and to suggest an explanation. The study used quantitative techniques to map child health in the community and identify a sub-sample for subsequent in-depth questioning and observation. What distinguished women with healthy and unhealthy children was the level of resources under their control and the way they managed them; their social support of lack of it; and their passive or active attitudes toward life. Detailed stories are presented for five of the women. Although biological explanations for ill health can lead to useful interventions, the social and economic problems of the 'multi-problem family' - well-recognized in industrialized countries - must also be addressed to improve child health.

Among Amerindian children living at high altitude in the Andes in southern Peru, high child mortality rates have been reported in the literature, especially in the perinatal and neonatal period. We compared mortality rates in children calculated from retrospective survey data in 86 rural families from 2 Aymara and 3 Quechua peasant communities living at the same level of altitude (3825 m) in southern Peru. Relations between land tenure, socio-cultural factors and child mortality were studied, and methodological considerations in this field of interest are discussed. Checks on consistency of empirical data showed evidence for underreporting of neonatal female deaths with birth order 3 and more. Perinatal (124 vs 34 per 1000 births) and infant mortality (223 vs 111 per 1000 live births) was significantly higher in Aymara compared with Quechua children, but no difference was found after the first year of life. A short pregnancy interval was associated with an elevated perinatal and infant mortality rate, and a similar albeit insignificant association was found with increased maternal age. Amount of land owned and birth order were not related with child mortality. Although levels of maternal education are generally low in both cultures, a consistent decline in infant and child mortality was found with the amount of years mothers had attended school. However, the results suggest a U-shaped relationship between the amount of years of parental education and perinatal mortality in offspring. Late fetal and early neonatal mortality were particularly high in one Aymara community where mothers were found to have more years of education. Infanticide, a known phenomenon in the highlands of the Andes, is discussed in relation with the findings of the study. Although maternal and child health services are utilized by the majority of families in 4 of 5 study communities, 43 of 51 mothers under the age of 45 years reported that they delivered their last baby in the absence of traditional midwives or official medical supervision.

The number of children in foster care in California doubled from 27 534 in 1980 to more than 62 419 in 1988, representing approximately 1% of the child population in the state. Past studies have demonstrated that children in foster care have high rates of medical and mental health problems. An examination of all Medi-Cal-paid claims was undertaken to describe the utilization of health services by children in foster care. Although children in foster care represent 4% of Medi-Cal-eligible children younger than 18 years of age, they account for approximately 5% of children using Medi-Cal services and 6.7% of expenditures, representing a 23% greater utilization rate and 41% greater expenditure rate than all children covered by Medi-Cal. Using the entire Medi-Cal population younger than 18 years of age as a comparison group, examination of inpatient and outpatient service utilization for specific condition categories showed few differences between children in foster care and the comparison group except for mental health service utilization, where children in foster care were much higher users of services.

In 1986, pediatricians were invited to assist the Connecticut Department of Children and Youth Services to improve the health care of foster children. A questionnaire seeking the experience of pediatricians caring for foster children was sent to 470 members of the American Academy of Pediatrics in Connecticut. The results of this survey were used to make recommendations to the agency and are detailed in this article.

Medicaid, a government health insurance program which pays for medical care for poor families, has improved the delivery of health services to children who are poor or near-poor (just above the poverty level), including those who are of minority groups. But increases in the numbers of poor children and cuts in funding of the Medicaid program have occurred. The effects of these trends on the access of poor children to medical services is not known. Availability of health care for American children and adolescents was evaluated by surveying households; the sample consisted of 2,182 children aged 17 years and younger. The survey showed that 10 percent of children had no medical insurance; 10 percent had no source of medical care; and 18 percent commonly used medical services at emergency rooms, community clinics, or hospital outpatient departments. Children who were poor, non-white, or without health insurance most often had not seen a physician within the past year. In addition, children without health insurance tended not to have up-to-date immunizations. These findings showed that poor, non-white, uninsured children were less likely to use a regular source of medical care; tended to use medical services at emergency rooms, community clinics, and hospital outpatient departments; and were often faced with financial barriers to health care. Thus, poor or non-white children had less access to medical care than affluent or white children, regardless of their insurance or health conditions. (Consumer Summary produced by Reliance Medical Information, Inc.)