Showing papers by "Neal Halfon published in 2009"

The health and cognitive growth of Latino toddlers: at risk or immigrant paradox?

Abstract: Epidemiologists have shown how birth outcomes are generally robust for immigrant Latina mothers, despite often situated in poor households, advanced by their strong prenatal and nutritional practices. But little is known about (1) how these protective factors may differ among Latino subgroups, (2) the extent to which birth outcomes, ongoing maternal practices, and family supports advance Latino toddlers’ health and physical growth, and (3) whether the same processes advance toddlers’ early cognitive growth. We drew on a national probability sample of 8,114 infants born in 2001, including 1,450 of diverse Latino origins. Data come from birth records, maternal interviews when the child was 9 and 24 months of age, and direct assessments of health status, physical growth, and cognitive proficiencies. Descriptive analyses compared Mexican-heritage and other Latino mothers and toddlers relative to middle-class whites. Multivariate regression techniques identified predictors of child health, weight, and BMI, as well as cognitive proficiencies at 24 months. Infants of Mexican-heritage or less acculturated Latina mothers displayed robust birth outcomes, compared with other ethnic groups. The low incidence of premature births and low birthweight among these mothers continued to advance their cognitive growth through 24 months of age. Yet Latino children overall displayed smaller gains in cognitive proficiencies between 9 and 24 months, compared with middle-class populations, attributable to Latinas’ lower levels of maternal education, weaker preliteracy practices, and a higher ratio of children per resident adult. Health practitioners should recognize that many Latina mothers display healthy prenatal practices and give birth to robust infants. But these early protective factors do not necessarily advance early cognitive growth. Screening practices, early interventions, and federal policy should become more sensitive to these countervailing dynamics.

An International Comparison of Early Childhood Initiatives: From Services to Systems

Abstract: It can be argued that much of the evidence generated in the United States on the importance of early childhood to future health and attainment has had a greater effect on the national policies of other countries than it has in the U.S., which lacks a national policy agenda for young children. However, the U.S. is not the only country to struggle with the direction early childhood policy should take: England, Canada, and Australia all started with similarly fragmented early childhood services, and have tended to favor market-based solutions with limited reliance on the welfare state. This report describes some of the components of all four countries’ efforts to develop policies that produce lasting gains for their youngest citizens. The authors also consider the implications of experiences in England, Canada, and Australia for the development of early childhood policy in the U.S. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. This and other Fund publications are available online at www.commonwealthfund.org. To learn more about new publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1241.

Innovation networks: a strategy to transform primary health care.

Abstract: UPGRADING PRIMARY CARE IS KEY TO REALIZING THE promise of health care reform to improve access and quality while reducing costs. Promising models, such as the patient-centered medical home and new measurement systems for detecting better population outcomes, require primary care clinicians to develop innovative ways of organizing care. Because new and improved approaches are not easily transplanted directly into practice, transforming primary health care will be virtually impossible without a system for innovating, testing, and providing what works. Primary health care innovation networks can accelerate primary care transformation by harnessing the collective intelligence and motivation of the medical community. Collaborative networks of primary care practices can enhance the capability of individual practices, as well as the capacity of local primary care systems, to improve health outcomes. One example is the Cincinnati Children’s PhysicianHospital Organization, which is a network of 40 independently owned and operated practices that have developed a shared infrastructure led by a board of practice leaders. The Cincinnati Children’s Physician-Hospital Organization provides centralized technical support for quality improvement and a shared registry for population management. Novel payfor-performance approaches were implemented that focused on improving population-level outcomes for children with asthma that created incentives for improvement within and across practices. These efforts contributed to substantial improvement in care delivery for 13 000 asthmatic children, including use of written self-management plans, controller medications, and influenza vaccinations. Although large organized health care systems like Cincinnati Children’s Physician-Hospital Organization, the US Department of Veterans Affairs, and Kaiser Permanente have the resources and power to accomplish such changes, more than two-thirds of care in the United States is delivered by practices that are not part of such systems. Providing policy and practice supports for these primary care practices poses an enormous challenge. Most research on primary care improvement has focused on practice-level improvement and has involved relatively small numbers of practices. Advances necessary to transform primary care will require a better understanding of how to align improvements across practice, community, health plan, and regional levels of the health care system. Engineering such improvement and understanding of what strategies are likely to work across diverse local contexts will require participation of large numbers of practices and communities. Research needs to go beyond simply describing and analyzing the barriers to providing better care, and do much better at finding creative solutions, experimenting to determine what works, and understanding what it takes to spread and scale new effective care strategies. Ways to promote active involvement of clinicians in innovating and adapting new ideas are needed by harnessing the collective intelligence and motivation of individual clinicians, organizations, and communities to transform care.

Pediatricians' roles in the provision of developmental services: an international study.

Abstract: Objective: To understand how early childhood developmental services are provided in other countries in comparison with the United States. Background: Recent surveys document gaps in developmental services provided in the United States. Understanding pediatrician roles in other industrialized countries may shed light on how to meet emerging professional expectations around health promotion care and developmental services. Design: Using a typology of preventive and health promotion care, we conducted structured interviews and case vignettes to examine the roles of health professionals in (1) developmental assessment, (2) anticipatory guidance/health promotion, (3) problem-focused counseling, and (4) coordination of service needs. Participants included 20 child health experts and key informants in 10 countries. Roles and systems of providers of care were categorized into several organizational approaches based on these results. Results: Pediatricians provide the continuum of primary care developmental services in only a few countries. In contrast to the United States, most of the studied countries have complementary roles for pediatricians and other nonphysician clinicians in preventive care. In many countries, nurses or general practice physicians provide most basic preventive care whereas pediatricians provide more specialized care for developmental/behavioral problems and chronic medical conditions. Conclusions: Recent studies that have documented the poor quality of early childhood health care are pressuring the US pediatric profession to meet increasing expectations in developmental services. Although US pediatricians struggle to incorporate recommendations into their daily practice, most other countries place responsibility for some preventive developmental services with community-based nurses or general practice physicians.

The relevance of health reform to community health and development

Abstract: Over the past twelve months, Congress and the nation have been engaged in a discussion about how to make significant changes in the provision of health insurance and the financing of health care in the United States. The debate has seen its highs and lows: from the raucous August town hall meetings and charges that the reform would institute “death panels” for the elderly and lead to government-run health care to more candid conversations about the affordability of health insurance for typical Americans and the real impact of an inefficient and underperforming health-care system on the U.S. economy.