Determinants of Children's Primary Health Care Use

We review factors that influence children's use of primary health care services. Predictors of pediatric health care use include child health status, child mental health, parent and family functioning, demographic characteristics, and access to health care services. Health services research is marked by inconsistencies due to varying approaches to measurement, population sampling, and analysis, and models that do not incorporate situational factors. We present recommendations for practicing clinicians and discuss suggestions for future research to help identify additional factors that may influence a parent's decision to seek help from pediatric physicians. Health care use is determined by multiple factors, and complex models will lead to improved strategies for maximizing health status and establishing optimal pediatric care.     

Family Support and Mental Health Service Use Among Suicidal Adolescents

Despite the fact that multiple evidence-based treatments exist for suicidal adolescents, these youth are unlikely to engage in mental health treatment. While family members can be influential in connecting adolescents to mental health care, suicidal youth are more likely to be exposed to family environments characterized by abuse, neglect, and to have poorer parent–child attachment quality than non-suicidal youth. This study analyzed data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) to examine the relationships between perceived levels of parental support, symptom severity, and mental health service use in a nationally representative sample of suicidal adolescents in the U.S. (n = 1804). Higher levels of parental support were associated with a lower likelihood of mental health service use, lower levels of depression, and lower likelihood of an actual suicide attempt. Additionally, the presence of a suicide attempt and higher levels of depression were associated with a higher likelihood of mental health service use. When mediation effects were tested, the presence of a suicide attempt partially mediated the relationship between parental support and mental health service use. Implications discussed include the protective nature of parental support the need for more family-based interventions for this population.     

Behavior Problems in Young Children With or At Risk for Developmental Delay

We examined the prevalence of behavior problems and their relationship to child, parent, and family factors in 76 children with or at risk for developmental delay. Parents reported that 42% of the children had behavior problems. Child Behavior Checklist (CBC) scores revealed that 25% of the sample scored above the borderline cutoff. Although the total, externalizing, and internalizing mean CBC scores did not differ from the normative group (same-aged peers without developmental delay), each of the syndrome subscales was significantly higher in the study group. The Reiss Scales for Children's Dual Diagnosis revealed that, as compared to older children (4 years) with developmental delay, the study sample scored significantly lower on the total score and 8 of the 10 subscales. Increased CBC total scores were significantly related to dependency and management of the child, birth weight, gestational length, paternal illness, maternal depression, perceived personal burden of care, maternal escape-avoidance coping strategy, family disharmony, and financial stress. CBC total scores were significantly negatively correlated with being of a multiple birth, paternal education, maternal employment, two-parent family, family social support, and family income. Multiple regression analyses revealed that an empirically-derived combination of child, parent, and family variables accounted for 31% of the variance in CBC total scores. Our findings suggest that 2-year old children with or at-risk for developmental delay may already be showing signs of increased risk of behavior problems relative to peers without developmental delay. We identified several child, parent, and family variables that may help to pinpoint children at increased riskxs for psychopathology.     

Child care and mother-child interaction in the first 3 years of life. NICHD Early Child Care Research Network

Relations between nonmaternal child care and ratings of maternal sensitivity and child positive engagement during mother-child interaction at 6, 15, 24, and 36 months were examined for 1,274 mothers and their children participating in the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care. In longitudinal analyses that controlled for selection, child, and family predictors, child care was a small but significant predictor of maternal sensitivity and child engagement. For the whole sample, including families who did and did not use child care, more hours of child care predicted less maternal sensitivity and less positive child engagement. For children who were observed in child care, higher quality child care predicted greater maternal sensitivity, and more child-care hours predicted less child engagement. The effects of child care on mother-child interaction were much smaller in the analytical models than the effects of maternal education but were similar in size to the effects of maternal depression and child difficult temperament. Patterns of association with child care did not differ significantly across ages of assessment.     

Family climate of routine asthma care: associating perceived burden and mother-child interaction patterns to child well-being

This preliminary report links the literatures on family asthma management practices and on the characteristics of family interaction patterns thought to influence children's adjustment to a chronic physical illness. Specifically, this study of 60 families with a child with asthma examined the extent to which perceived burden of routine asthma care affected child mental health via its influence on parent-child interaction patterns. Mothers completed a measure of asthma management routine burden, mother and child were observed in a 15-minute interaction task, and children completed measures of child anxiety and asthma quality of life (QOL). Perceived routine burden significantly predicted child anxiety and QOL through its effect on mother-child rejection/criticism. The same pattern did not hold for mother intrusiveness/control. The results are discussed in terms of how overall family climate and regulation of routines affects child well-being. Implications for clinical practice and limitations of the study are provided.     

Family Resilience and the Management of Fibromyalgia: Implications for Family Therapists

Fibromyalgia Syndrome (FMS) is one of the most troubling rheumatic disorders for patients, significant others, and the health care providers who treat them. Responses from 150 participants provided valuable information on the relationship between family resilience and the management of fibromyalgia. Self reported family stressors, strains, and distress were significantly associated with an increase in health problems/functional disability, whereas family hardiness and family social support were associated with a decrease. Family stressors and family strains were also positively associated with the frequency of medication use. Medical family therapy interventions that consider the familial context are recommended for treatment. Additional implications for clinical practice and future research are discussed. J. Cameron Preece, PhD, Sage Health Care, PLLC, 339 Allumbaugh Street, Boise, ID 83704. Jonathan G. Sandberg, PhD, Department of Marriage and Family Therapy, Syracuse University, Syracuse, NY 13244. (jgandbe@syr.edu) Special thanks go to Linda Stone Fish, PhD, for her support and guidance throughout the study.     

Influence of Perceived Racial Discrimination on the Health of Immigrant Children in Canada

Racial discrimination and racism are recognized as determinants of health for adults. Less is understood regarding the influence of discrimination targeted towards parents, the family, or the cultural and children’s health. Data from the New Canadian Children and Youth Study (NCCYS) are used in this paper. The NCCYS is a national, longitudinal study of children whose families settled in urban centers of Canada. We analyzed data from individuals who settled in the metropolitan Vancouver area from six ethnic communities: Mainland China, Hong Kong, the Philippines, Iran, Afghanistan, and the Punjab who were interviewed at two times, approximately 2 years apart. Data were collected on perceived parental, family, and cultural discrimination. Our dependent variable was parent-reported child health status. Over time, perceived parental discrimination and perceived family discrimination decreased; and both forms of discrimination had a positive effect on child health. In contrast, perceived cultural discrimination increased over time and had a negative effect on child health at both times. Different forms of discrimination have different effects on child health. Racial discrimination is complex. Its influence on either increasing family cohesion, and thereby leading to improved health, or increasing stress, thereby leading to poorer health needs to be explored further.     

Early Childhood Care Trends and Associations with Child Health Well-being in China: Evidence from the CHNS 1991 to 2011 Data

It has become increasingly common for young children to be taken care of by multiple caregivers in China after the socio-economic reforms. Complex migration patterns and high female labour force participation have led to children receiving care from various individuals in different contexts. However, little is known about how childcare arrangements are associated with child health well-being. This study examines various early childhood caregivers and their influences on children’s physical health in China. Using data from the China Health and Nutrition Survey (CHNS 1991–2011) with 3,470 children aged 2 to 6, we first identified different types of childcare arrangements in and outside of the household based on who provides the care, where they provide the care, and the intensity of the care. Then we examined the relationship between various childcare arrangements and health outcomes for children. Overall, household members undertook early childhood care tasks in China, with an increase in grandparents as primary caregivers between 1991 and 2011. The proportion of children receiving formal childcare fluctuated around 20% during this period. The findings suggest that: 1) primary caregiver in the household other than parents is not associated with undesirable physical health outcomes; 2) formal childcare outside the household is associated with higher height and lower BMI scores; 3) primary caregivers in the household, particular grandparents, moderate the association between childcare arrangements outside the household and children’s health outcomes. It yields an implication that early childhood care policies incorporating multiple caregivers would benefit children’s well-being in China.

     

不同语境下的初级卫生保健

初级卫生保健一词在国内文献中涵义不同,研究发现《阿拉木图宣言》中的初级卫生保健更多的具有卫生体系变革的涵义,强调公平性、多部门合作、社区参与、适宜技术和适宜人力的原则;选择性初级卫生保健则以推广具有成本效益的卫生干预措施为重点;国内政策语境下的初级卫生保健则更多的是具体的卫生服务内容。     

Referral Source Differences in Functional Impairment Levels for Children Served in the Comprehensive Community Mental Health Services for Children and Their Families Program

We report one of the first multi-site investigations into referral source variation in functional impairment for children with serious emotional disturbance served in systems of care settings. Baseline data collected as part of the national evaluation for the Comprehensive Community Mental Health Services for Children and Their Families Program was used to assess the comparability of functional status for children referred from traditional mental health versus non-mental health agencies. Results indicate that children referred from child welfare and family groups have significantly lower levels of overall dysfunction than those referred from mental health, while children referred from school and juvenile justice agencies have comparable levels. Clinical and research implications are discussed.     

Behavioral Health Integration in Health Care Settings: Lessons Learned from a Pediatric Hospital Primary Care System

Behavioral health integration within primary care has been evolving, but literature traditionally focuses on smaller scale efforts. We detail how behavioral health has been integrated across a large, urban pediatric hospital system’s six primary care clinics (serving over 35,000 children annually and insured predominately through Medicaid) and discuss strategies for success in sustaining and expanding efforts to achieve effective integration of behavioral health into primary care. In a time span of 3 years, the clinics have implemented routine, universal behavioral health screening at well child visits, participated in a 15-month behavioral health screening quality improvement learning collaborative, and integrated the work of psychologists and psychiatrists. Additional work remains to be done in improving family engagement, further expanding services, and ensuring sustainability.     

Implementing family‐friendly employment practices in banking industry: Evidences from some African and Asian countries

We examined the effects of family‐friendly policies (child‐care benefits and work flexibility benefits) on organizational commitment and work–family conflict in four developing countries: China, India, Kenya, and Thailand. We also explored the boundary condition (e.g., perceived importance of family‐friendly programmes) under which family‐friendly policies are more (or less) effective in influencing organizational commitment and reducing work–family conflict. Results revealed national similarities on the effect of flexibility benefits on organizational commitment and work–family conflict. Specifically, we found that across the four countries work flexibility‐related family‐friendly policy was positively related to organizational commitment and negatively to perceived work–family conflict among those who perceived this policy as more important than less important. Instead, national variations are found in the results regarding child‐care benefits. Among these four countries, Kenya and Thailand are two countries in which child‐care‐related family‐friendly policies showed a significant and positive relationship with organizational commitment and/or a significant and negative relationship with work–family conflict. We also found child‐care‐related family‐friendly policies had differential effect among people with various perception of policy importance in Kenya and Thailand, but not in China and India. Particularly, child‐care‐related family‐friendly policy results in greater organizational commitment and lower work–family conflict among those who perceived this policy as more important than less important in Kenya and Thailand. Implications for cross‐cultural research, theory and practice are discussed.     

Caregiving for Patients in Vegetative and Minimally Conscious States: Perceived Burden as a Mediator in Caregivers’ Expression of Needs and Symptoms of Depression and Anxiety

Involvement of family members is crucial to provide daily informal caring to patients in vegetative state and minimally conscious state. Previous studies showed that perceived burden is a risk factor for informal caregivers as it increases psychophysical distress. This research further investigated the relationship between these factors and aimed at providing a model that thoroughly describes this mechanism of functioning. In the frame of a national survey on people with disorders of consciousness, 487 informal caregivers of children and adult patients in vegetative and minimally conscious state were administered measures of depression, anxiety, caregiver needs, and family strain. Regression models proposed by Baron and Kenny and the Sobel test were adopted to investigate the relationship between depressive and anxiety symptoms, perceived burden and needs expressed. Our study shows that the relation between those symptoms and needs is mediated by burden, where higher burden accentuates and lower burden mitigates the needs expressed by caregivers. Our findings demonstrate that psychosocial components of the burden perceived by caregivers of patients with disorders of consciousness play a key role in shaping those caregivers’ needs, especially their needs for information and communication. We recommend implementation of comprehensive steps to meet the needs of these caregivers, steps that incorporate improved economic and public health programs, social support, and use of psychological interventions to ameliorate caregivers’ psychological distress and decrease their burden.     

Relationship between Mental Health and Burden among Primary Caregivers of Outpatients with Schizophrenia

There is growing recognition that caring for a patient with schizophrenia often results in high levels of perceived burden and poorer overall mental health for caregivers. A quantitative cross‐sectional design and standardized instruments were used to collect data from 355 primary caregivers of adults in outpatient care with schizophrenia in China. Structural equation modeling was used to examine the association between caregiver burden and mental health among primary caregivers and whether this association is influenced by personality, coping style, and family functioning, based on a diathesis–stress perspective. Goodness‐of‐fit indices (χ²/df = 1.406, GFI = 0.919, CFI = 0.957, etc.) confirmed that the modified model fit the data well. In line with the diathesis–stress model, and with this study's hypotheses, we found that caregiver burden was significantly related to mental health outcomes directly. The final model showed that personality traits, coping style, and family function influenced the relationship between caregiver burden and mental health. The neuroticism personality traits have a direct effect on caregiver burden and family functioning in this sample. Coping style had a direct effect on the caregiver burden, and family functioning had a direct effect on the caregiver burden. Our final model about primary caregivers can be applied clinically to predict mental health outcomes from caregiver burden.     

国际健康目标与卫生改革的新导向——重视预防保健的作用

由于认识到卫生系统的大部分资源主要花费在疾病的治疗上,这种资源配置不当不仅导致巨额医疗费用负担和低效率,并没有获得好的健康结果;因此,近年许多发达国家的健康目标与卫生改革出现了一个新的导向,日益重视预防保健的作用;并采取优先选择的方式,确保资源优先配置给对人群健康最需要、资源投入最具有成本效果的保健服务。这种改革已取得了一些成效。这一改革导向对我国正在进行的医药卫生体制改革的制度设计与政策开发提供了启示。     

Motivation for Dental Home Care: Testing a Self‐Determination Theory Model1

The present research developed the Self‐Regulation for Dental Home Care Questionnaire (SRDHCQ), based on self‐determination theory (SDT; Deci & Ryan, 2000 ), and used it in an SDT process model of dental health behaviors and self‐rated oral health. In this model, patients' perceptions of autonomy‐supportive (relative to controlling) dental professionals were expected to positively predict patients' psychological needs satisfaction in treatment. Needs satisfaction was expected to be positively related to autonomous motivation for dental home care and perceived dental competence, which were expected to be positively associated with self‐rated oral health and dental health behaviors. Confirmatory factor analysis of the 5‐factor SRDHCQ model fit the data very well, and a structural equation model supported the hypothesized process model.     

Psychometric Properties of the Primary Care Behavioral Health Screen

The Primary Care Behavioral Health Screen (PCBHS) is a self-report instrument developed to screen for behavioral health problems in primary care settings. The present paper describes development of the PCBHS and reports findings from item analyses and studies examining the instrument’s convergent validity and test–retest reliability. Results suggest the PCBHS is a useful and valid method for screening a variety of behavioral health problems in a busy primary care practice. Recommendations for further research on the PCBHS are provided.     

Promoting Mental Health Equity: The Role of Integrated Care

People suffering from mental illness experience poor physical health outcomes, including an average life expectancy of 25 years less than the rest of the population. Stigma is a frequent barrier to accessing behavioral health services. Health equity refers to the opportunity for all people to experience optimal health; the social determinants of health can enable or impede health equity. Recommendations from the U.S. government and the World Health Organization support mental health promotion while recognizing barriers that preclude health equity. The United States Preventive Services Task Force recently recommended screening all adults for depression. The Satcher Health Leadership Institute at the Morehouse School of Medicine (SHLI/MSM) is committed to developing leaders who will help to reduce health disparities as the nation moves toward health equity. The SHLI/MSM Integrated Care Leadership Program (ICLP) provides clinical and administrative healthcare professionals with knowledge and training to develop culturally-sensitive integrated care practices. Integrating behavioral health and primary care improves quality of life and lowers health system costs.     

Primary Care Medical Provider Attitudes Regarding Mental Health and Behavioral Medicine in Integrated and Non-integrated Primary Care Practice Settings

Primary care medical providers (PCPs) have become de facto providers of services for the management of both mental and chronic illnesses. Although some reports suggest that PCPs favor having Behavioral Health colleagues provide behavioral health services in primary care, others demonstrate this view is necessarily not universal. We examined attitudes regarding behavioral health services among PCPs in practices that offer such services via onsite behavioral health providers (n = 31) and those that do not (n = 62). We compared referral rates and perceived need for and helpfulness of behavioral health colleagues in treating mental health/behavioral medicine issues. In both samples, perceived need was variable (5?C100%), as were PCPs?? views of their own competence in mental health/behavioral medicine diagnosis and treatment. Interestingly, neither sample rated perceived access to behavioral health providers exceptionally high. Referral rates and views about the helpfulness of behavioral health services, except in relation to depression and anxiety, were lower than expected. These results suggest a need for increased collaboration with and education of PCPs about the roles and skills of behavioral health professionals.     

Behavioral Health Consultation and Primary Care: Lessons Learned

This article provides an overview of 20 years of professional experiences with developing and implementing a model for integrating behavioral health services into primary care. The Primary Care Behavioral Health (PCBH) model is designed to provide immediate access to behavioral care for a large number of primary care patients by positioning a behavioral health consultant in the exam room area to function as a core member of the primary care team. In an initial era of discovery, the authors were directly involved in developing and testing a variety of new approaches to providing behavioral health services in general medicine. In a second era focused on feasibility, the authors worked with Kaiser Permanente, the United States Air Force and Navy, the Veteran’s Administration, and the Bureau of Primary Care to system test this innovative model of integrated care. Now in an era devoted to dissemination, the authors review the various roles formal research, system level quality improvement initiatives and stakeholder analysis play in promoting integrated care. The authors also describe current efforts to (1) create a tool that helps systems develop integration targets and (2) use the PCBH model as a platform for teaching medical residents and behavioral health providers to work together in a redesigned primary care team model.