2009 Child Health Services Research Interest Group Meeting
Call for Panels Abstracts
Reducing Disparities in Children's Healthcare
Quality: A Research and Action Agenda
Moderator: Denise Dougherty, Ph.D.
Saturday, June 27 ♦ 10:45 a.m.–12:15 p.m.
Panel Overview: Disparities in healthcare quality for
children can have both immediate and long-term
consequences for the children, their families, and
society. To date, most of the research and action to
reduce disparities in quality has not focused on this
population.
● Current Evidence: Disparities in Children's
Healthcare Quality and Strategies for Their
Reduction
Denise Dougherty, Ph.D.; Terceira Berdahl, Ph.D.;
Pamela Owens, Ph.D.; Lisa Simpson, M.B., B.Ch.,
M.P.H., F.A.A.P.; Marie McCormick, M.D., Sc.D.
Presented by: Denise Dougherty, Ph.D., Senior
Advisor, Child Health and Quality Improvement, Office of
Extramural Research, Education and Priority
Populations, USDHHS Agency for Healthcare Research
and Quality, 540 Gaither Road, Rockville, MD, 20850,
Phone: (301) 427-1868, Email:
denise.dougherty@ahrq.hhs.gov
Research Objective: To examine recent data on
disparities in children's healthcare quality and conduct a
literature search on the effectiveness of efforts to reduce
such disparities.
Study Design: Recent data: We selected data on
disparities by race/ethnicity, insurance, and income
using children's healthcare quality measures in AHRQ's
Medical Expenditure Panel Survey and Healthcare Cost
and Utilization Project State Inpatient Databases.
Literature search: We searched for studies that
evaluated effort to reduce disparities in quality for racial
and ethnic minority, low-income, and publicly or
uninsured children, and evaluated their methodological
quality and findings.
Population Studied: Children ages 0-17 who were
black non-Hispanic (BNHC), Hispanic of any race (H),
Asian/Pacific Islander (APIC), American Indian/Native
American (AIANC), and White Non-Hispanic (WNHC),
by income, and insurance status and source (e.g., public
v private).
Principal Findings: Results varied by race/ethnicity,
income, and insurance across multiple measures.
Examples include: Using HCUP, some racial and ethnic
minority children may be at higher risk than their WNH
counterparts for ambulatory-care sensitive
hospitalizations and inpatient medical errors. For
example, Hispanic children (HC) in most income groups
were .6 to .7 times as likely to be admitted for diabetes
as WNHC, but HC in all income groups were 1.3 to 1.5
times as likely to be admitted for a urinary tract infection
as WNHC. Using MEPS, Publicly insured AIANC were
less likely to report that doctors showed respect during
visits than publicly insured WNHC (0.88 v 0.93).
Literature review: Few studies report on implementation
of quality improvement strategies in key services for
vulnerable children. Studies vary in methodological
quality, but several show promising directions for action.
Conclusions: Analyzing data on disparities by
race/ethnicity, insurance and income together provides
direction for disparities reduction targets. More tarteted
research is needed to identify effective strategies to
improve care for these subpopulations.
Implications: Enough is known about disparities in
healthcare quality for children that some immediate
action can be taken. A targeted research agenda can
enhance the evidence base for quality improvement.
Funding Source(s): AHRQ
● Starting Early to Reduce Disparities—A Research
Agenda
Renee Jenkins, M.D., F.A.A.P.; Ivor Horn, M.D., M.P.H.,
F.A.A.P.; Tina Cheng, M.D., M.P.H., F.A.A.P.; Jill
Joseph, M.D., Ph.D.; Denice Cora-Bramble, M.D.,
M.B.A., F.A.A.P.; Lee Pachter, M.D., Ph.D.
Presented by: Renee Jenkins, M.D., F.A.A.P.,
Professor, Department of Medicine and Pediatrics and
DC/Baltimore Research Center on Child Health
Disparities, Howard University School of Medicine, 1840
Seventh Street NW, Washington, DC 20001, Phone:
(202) 865- 8342/4569, Email: rjenkins@howard.edu
Research Objective: To develop a research action
agenda for eliminating child health disparities. To share
a research action agenda for eliminating child health
disparities developed at a multidisciplinary meeting of
researchers, practitioners and funders who met
November 6-7.
Study Design: On November 6–7, 2008, seventy
multidisciplinary researchers, practitioners and funders
met at the Kellogg Conference Center of Gallaudet
University in Washington, DC. for the conference
Starting Early: A Life Course Perspective on Child
Health Disparities. The meeting was led by the DCBaltimore Research Center on Child Health Disparities,
and sponsored by the National Center on Minority Health
and Health Disparities, Eunice Kennedy Shriver National
Institute of Child Health and Human Development,
Agency for Healthcare Quality and Research,
Commonwealth Fund, Lucile Packard Foundation for
Children’s Health, Robert Wood Johnson Foundation,
American Academy of Pediatrics, and the Academic
Pediatric Association. Subsequently, planning committee
members have worked with meeting participants to
develop a summary of the meeting and its
recommendations to be published in a variety of venues
along with papers commissioned for the conference.
Population Studied: Children vulnerable to racial and
ethnic, socioeconomic, and other (e.g., geographic)
disparities in health and health care.
Principal Findings: Conference participants agreed to
the call for a multidisciplinary approach to understanding
and reducing child health disparities, a working definition
of disparities, a conceptual framework for future
research, and a research and training agenda. The
presenter will provide details focusing specifically on
eliminating disparities in healthcare quality.
Conclusions: Improving the health of all children is not
only a social priority in its own right, but also essential to
ensure the future health of our nation. The conference
findings are critical to shapring the research agenda for
eliminating child health disparities.
Implications: The research and action agenda has
profound implications for research policy.
Funding Source(s): NICHD, National Center on
Minority Health and Health Disparities, Commonwealth
Fund, AHRQ, RWJF, AAP, APA, Packard Foundation
● Policy Opportunities for Reducing Children’s
Healthcare Quality Disparities
Lisa Simpson, M.B., B.Ch., M.P.H., F.A.A.P.
Presented by: Lisa Simpson, M.B., B.Ch., M.P.H.,
F.A.A.P., Director, Children's Policy Research Center,
Cincinnati Children's Medical Center, 3333 Burnet
Avenue, MLC 7014, Cincinnati, OH 45229, Phone: (513)
636-2781, Email: lisa.simpson@cchmc.org
Research Objective: The new administration in
Washington offers the most promising opportunity for
reducing children’s healthcare quality disparities in
decades, even in the context of economic stress. This
presentation will summarize these and additional
opportunities up through the time of the CHSR meeting,
identifying where the child health community can be
proactive in ensuring that all these new resources – both
monetary and philosophical – are used for the benefit of
our most vulnerable children.
Principal Findings: Over the past decade, the child
health services research field has developed compelling
information about the nature of child healthcare quality
disparities, and has begun to develop and assess
disparities reduction strategies applicable to vulnerable
children. However, the Child Health Insurance Program
Reauthorization Act (CHIPRA, enacted in January
2009), realizes that much more movement is needed.
CHIPRA puts development and implementation of
quality measures and quality improvement strategies on
a fast track for the tens of millions of our children
currently covered by CHIP and Medicaid, and those new
subpopulations included in the legislation. CHIPRA is
not blind to the needs of those children affected by
racial, ethnic and socioeconomic disparities, specifying
that measures identified or developed under its authority
must be able to perform comparative analyses of these
disparities. In addition to CHIPRA, other policy
developments enacted or in progress can be employed
to reduce disparities in quality. These include enhanced
funds for comparative effectiveness research and
another $10 billion for NIH research. Health information
technology enhancements in the stimulus bill, in addition
to CHIPRA’s call for development of a child-specific
electronic health record, should accelerate the real-time
collection and immediate use of quality measures and
improvement strategies for our most vulnerable children,
as long as EHR standards permit identification of lowincome and racial and ethnic minority children. Specific
details will be presented.
Conclusions: Unprecedented opportunities now exist
for improving healthcare quality and reducing disparities
in quality for children.
Implications: Child health services researchers and
child health policymakers at multiple levels will be able to
generate and take action on opportunities discussed at
this session.
Current Innovations and Challenges in Childhood
Immunization
Moderator: Matthew Davis, M.D., M.A.P.P.
Saturday, June 27 ♦ 10:45 a.m.–12:15 p.m.
Panel Overview: Childhood immunization has been
called one of the great public health achievements of the
20th century, and an unprecedented number of newly
recommended vaccines in recent years present many
fresh opportunities to protect children’s and adolescents’
health. However, with innovations in immunization come
tough challenges at many levels – patient, physician,
and policy. The overarching objective of this panel is to
address major challenges to recent innovations in child
and adolescent vaccination efforts, and to discuss
implications for policy, delivery, and/or practice for each.
Cost and reimburstment for combination vaccines:
There are now more combination vaccines available
than ever before, but there may be adverse financial
consequences for practices that try to implement them.
Sarah Clark will describe her team’s multistate, practicelevel study to examine the purchase costs and
reimbursements for practices that have, and have not,
implemented a pentavalent combination vaccine.
Information accuracy for reminders and recall:
Reminder/recall systems can work very well in tandem
with immunization information systems (IIS; also known
as registries). However, little is known about the
accuracy of contact information in IIS. Kevin
Dombkowski will present his team’s study of IIS contact
data across 15 counties in Michigan. Modeling uptake of
HPV vaccines: Human papillomavirus vaccine offers
promise as an anti-cancer vaccine, but published models
of its uptake may overestimate the pace and height of
public acceptance. Mandy Dempsey will present her
team’s novel models of population uptake of HPV
vaccine, with and without a school mandate. Examining
the vaccine R&D pipeline: The recent pace of vaccine
licensure is unprecedented, with uncertain implications
for the future. Matt Davis will describe his team’s study
of the vaccine research and development pipeline,
including the ratio of failures to successes and how that
may affect future investment in vaccines.
● Policy Implications of the Expanding Vaccine R&D
Pipeline
Matthew Davis, M.D., M.A.P.P.; Amy Butchart, M.P.H.;
Margaret Coleman, Ph.D.; Dianne Singer, M.P.H.; John
Wheeler, Ph.D.; Gary Freed, M.D., M.P.H.
Presented by: Matthew Davis, M.D., M.A.P.P.,
Associate Professor, Pediatrics, University of Michigan,
300 North Ingalls, Ann Arbor, MI 48109-5456, Phone:
(734) 615-3508, Email: mattdav@med.umich.edu
Research Objective: In recent years, there have been
an unprecedented number of new vaccines
recommended for children, adolescents, and adults.
This apparent success of research and development for
vaccines may contrast with the track record of
therapeutic drug development, which indicates that there
are many failed prospects for each success. The
investigators undertook this study to characterize trends
in development of vaccines and ratios of failures to
successes.
Study Design: The investigators examined a proprietary
industry database (Pharmaprojects) to characterize
trends in the vaccine R&D pipeline (# of vaccine
originators; # of vaccines in preclinical or clinical
development) for the period 1995-2008. The
investigators used the same database to identify
prophylactic non-influenza vaccines in preclinical or any
phase of clinical trials development for two “cohorts” of
vaccines—those in active development in 1995 versus
those in 2000. The investigators tracked the
development of cohort vaccines to determine if they
were licensed in the United States (ie, succeeded),
ceased development (ie, failed), or remained in active
development. Follow-up was for 8 years (to use the
same duration for both cohorts), and a failure:success
ratio was determined for each follow-up period.
Vaccines in the 1995 cohort were excluded from the
2000 cohort. For purposes of comparison, the
investigators examined the same outcomes for nonprophylactic-vaccine pharmaceuticals.
Population Studied: Prophylactic vaccines in
development, 1995-2008.
Principal Findings: Pipeline trends - From 1995
through 2008, the number of prophylactic vaccine
originators more than doubled (from 62 to 136). During
the same time period, the number of companies in the
pharmaceutical industry overall more than tripled (from
567 to 1951). From 1995 through 2008, the total
number of vaccines in the development pipeline
(preclinical or clinical trials) more than doubled, from 144
to 354. Failure: success ratios - Among 142 vaccines in
development in 1995, by 8 years later 5% (n=7) had
been licensed, 75% had ceased development, and 20%
remained in active development. This translated to a
failure:success ratio of 15:1. Among 167 vaccines in
development in 2000, 2% (n=4) had been licensed 8
years later, while 82% had ceased development and
16% remained in active development. This translated to
a failure:success ratio of 34:1. In comparison, among
non-prophylactic-vaccine pharmaceuticals, there was a
10:1 failure:success ratio for drugs in active
development in 1995, and a 21:1 ratio for drugs in active
development in 2000.
Conclusions: Recent recommendations of several
newly developed vaccines reflect greater vaccine
development activity in private industry. However, there
has also been an increasing ratio of failures to
successes over time, mirroring a similar trend for
pharmaceuticals overall.
Implications: Increasing proportions of failures may
drive up research and development costs for
manufacturers, with potential implications for future
investment in vaccine development.
Funding Source(s): CDC
● Innovations to Improve the Effectiveness of
Reminder and Recall Notification
Kevin Dombkowski, Dr.P.H.; Sarah Leasure, B.S.;
Adrienne Nickles, B.S.; Sarah Clark, M.P.H.
Presented by: Kevin Dombkowski, Dr.P.H., Research
Assistant Professor, Pediatrics, University of Michigan,
300 NIB, Ann Arbor, MI 48109-5456, Phone: (734) 6153508, Email: kjd@med.umich.edu
Research Objective: Immunization information systems
(IIS) can be an effective mechanism to generate recall
notices for children that are overdue for recommended
vaccinations. Little is known about the degree to which
the completeness and accuracy of parent contact
information in an IIS may affect mailed recall
notifications. The objective of this study was to 1)
evaluate the completeness and accuracy of parent
contact information in a statewide IIS; and 2) identify
potential strategies for improvement; and 3) test the
effectiveness of selected improvement strategies.
Study Design: The Michigan Care Improvement
Registry (MCIR) was used by local health departments
(LHDs) to identify overdue children and to generate
recall notices. LHD staff tracked the time required to
complete each recall notification cycle and also
documented each notice returned by the U.S. Postal
Service as being undeliverable. Returned recalls notices
were summarized by demographic characteristics of
children within each LHD jurisdiction. Potential sources
of alternative parent contact information sources were
identified through interviews conducted with LHD and
state immunization officials.
Population Studied: Children 7 months – 19 years
(2008-2009) in 15 Southwest Michigan counties who
were overdue for one or more ACIP recommended
vaccine dose.
Principal Findings: Seven LHDs mailed a total of
13,892 recall notices for children 6 months to 19 years
during January-November 2008. Overall, 33% of mailed
recall notices were returned as undeliverable. The
proportion of undeliverable mailed notices was greatest
among adolescents 11-20 years (39%), and lowest
among children 6-18 months (14%). The proportion of
undeliverable notices varied across the seven LHDs,
ranging from 11%-18% undeliverable for children 6-18
months; 14%-27% undeliverable for children 19-35
months; and 32%-45% for adolescents 11-19 years.
However, the rate of undeliverables for children 3-5 yrs
was consistent across LHDs at 20%.
Conclusions: A substantial number of children that are
overdue for recommended vaccinations cannot be
contacted by mail due to incomplete or inaccurate
address information. Incorrect parent contact
information varies widely across age groups and LHD
jurisdictions. Undeliverable recall notices are most
common among adolescents, a group for whom national
vaccination recommendations has recently been
expanded.
Implications: New strategies are needed to improve the
timeliness and accuracy of parent contact information in
order for registry-based reminder/recall efforts to be
more effective. The next phase of this study will conduct
randomized trials to assess the effectiveness alternative
information sources.
Funding Source(s): CDC
● Modeling the Impact of Parental Attitudes and
School Mandates on Uptake of HPV Vaccines among
Adolescents
Amanda Dempsey, M.D., Ph.D., M.P.H.; David Mendez,
Ph.D.
Presented by: Amanda Dempsey, M.D., Ph.D., M.P.H.,
Assistant Professor, Pediatrics, University of Michigan,
300 North Ingalls, Ann Arbor, MI 48109-5456, Phone:
(734) 615-3508, Email: adempsey@med.umich.edu
Research Objective: The clinical impact of human
papillomavirus (HPV) vaccination on cervical cancer and
other HPV-associated diseases has been predicted
using mathematical models. However, a significant
limitation of these models is that they assume nearinstantaneous and widespread (70-100%) vaccine
uptake among adolescent girls. The objectives of this
study were 1) to develop a more realistic mathematical
model of adolescent HPV vaccine uptake that
incorporated existing data on parental attitudes about
the vaccine and adolescent health care utilization
patterns; and 2) to use this model to explore the
potential impact of a school mandate for HPV
vaccination.
Study Design; We developed a dynamic,
compartmental model of HPV vaccine uptake among 1117 year old girls that spanned a 50-year time period.
Model parameters were derived from existing data on
parental attitudes about HPV vaccines, validated models
of health behavior, adolescent health care utilization
patterns and census data. Markov probability sampling
techniques were used to estimate vaccine utilization at
the population level. Sensitivity analyses were performed
to determine the impact of parameter assumptions and
uncertainties on model outputs.
Population Studied: A theoretical population of 11-17
year old girls and their parents.
Principal Findings: Under baseline, non-mandate
conditions, our model predicted that in the first year of
HPV vaccination programs first, second and third doses
of vaccine would be received by 25%, 17% and 7% of
adolescent girls, respectively. Seventy percent
vaccination coverage, the lower threshold value used in
previous studies assessing the clinical impact of HPV
vaccines, was not achieved until year 23 of the program.
Vaccine coverage after 50 years was 79%. Instituting
school mandates was predicted to increase HPV vaccine
utilization substantially, resulting in 19% of adolescent
girls fully vaccinated after the first year of vaccine
implementation, and 70% vaccination coverage by year
8 of vaccine availability. Maximal vaccination coverage,
90%, was achieved by year 43 of the program.
Conclusions: Given current parental sentiments about
HPV vaccination and existing patterns of adolescent
health care utilization, our results suggest that
assumptions about HPV vaccine uptake among
adolescents may have been too generous in previous
models. School mandates have the potential to improve
vaccination rates, but even with such policies high levels
of vaccine utilization could still take several years to
achieve.
Implications: Our results suggest that without
significant changes in adolescent health care utilization
patterns and/or parental attitudes, utilization of the HPV
vaccine by adolescents will be sub-optimal for many
years. School mandates are one policy that might
improve vaccine utilization, and several different types of
HPV vaccine-related school mandates are currently
under legislative consideration. However, to ensure that
the optimal policies are adopted, the potential impact of
these various types of HPV vaccine mandates should be
explored further.
● Private-Sector Cost and Reimbursement for
Vaccines: Financial Impact of Combination Vaccines
Sarah Clark, M.P.H.; Anne Cowan, M.P.H.; Gary Freed,
M.D., M.P.H.
Presented by: Sarah Clark, M.P.H., Research Assistant
Professor, Pediatrics, University of Michigan, 300 North
Ingalls, Ann Arbor, MI 48109-5456, Phone: (734) 6153508, Email: saclark@med.umich.edu
Research Objective: Combination vaccines are
endorsed as a way to both reduce the number of
injections for children and enhance immunization
coverage rates. However, anecdotal reports suggest that
the use of newer combination vaccines has a negative
financial impact on private practices. The objective of
this study was to compare the average per-child privatesector vaccine purchase cost and reimbursement across
the childhood immunization schedule for practices using
pentavalent (DTaP-IPV-HepB) combination vaccine vs
practices using no combination vaccines.
Study Design: From April to December 2007, a targeted
sample of private practices in 5 states reported their
prior 6 months of vaccine orders and their specific
reimbursement amounts for vaccine and administration
fees from their 3 most common non-Medicaid payers.
From this, we calculated cost and reimbursement per
dose for each vaccine purchased in the practice.
Vaccine cost, vaccine reimbursement, net yield (vaccine
reimbursement minus vaccine cost) and administration
fee reimbursement were calculated for a single child
across the childhood immunization schedule, based on
the specific vaccine products used in that practice and
assuming simultaneous administration of all
recommended doses at 2 m, 4 m, 6 m, 12-18 m, and 4-6
yrs. Rotavirus, hepatitis A, and influenza vaccine were
excluded because they were not routinely purchased by
all practices; for similar reasons the birth dose of
hepatitis B was also excluded.
Population Studied: Private pediatric practices across
5 states
Principal Findings: Of the 76 practices providing
detailed data for the study, 28 purchased pentavalent
combination vaccine, and 16 used no combination
vaccines. Mean vaccine purchase cost and
reimbursement were higher for the pentavalent
combination group, yet the “net yield” was lower.
Specifically, for the pentavalent group, vaccine purchase
cost for a prototypical child was $819.01 and vaccine
purchase reimbursement was $1001.39, for a net yield
of $182.38. In contrast, in the no combination group,
vaccine purchase cost was $751.72 and vaccine
purchase reimbursement was $986.82, for a net yield of
$235.10. Mean administration fee reimbursement was
lower for the pentavalent combination group than the no
combination group ($199.23 vs $311.95), consistent with
the lower number of injections compared to the no
combination group.
Conclusions: Private-sector reimbursement for
practices using pentavalent combination vaccine was
lower than for practices using separate vaccine
products. This financial disincentive may work against
efforts to promote the use of combination vaccines.
Implications: Public health officials and child health
providers have recommended combination vaccines as
a means to reduce the number of injections given to
young children. Successful promotion of combination
vaccines may require new policies for enhanced vaccine
administration fees, which would counteract the
economic disincentives identified in this study.
Funding Source(s): CDC
Health Literacy and Children
Moderator: William Cull, Ph.D.
Saturday, June 27 ♦ 10:45 a.m.–12:15 p.m.
Panel Overview: Increasing consideration is being
given to the difficulties that the US health care system
presents to patients and the consequences of patient
misunderstanding. Recommendations for action have
emanated primarily from adult medicine, but growing
attention is being devoted to the unique aspects of
health literacy related to children and pediatric health
care. The goal of this panel will be to provide the
attendee with a child-focused overview of the health
literacy problem. Papers will focus on the scope of the
problem for children and on different interventions to
increase parent understanding that have been
implemented in real-world pediatric settings. The session
will include a short introduction, four paper presentations
with questions and answers and a short general
discussion. The first paper, by Yin (et al.), will use
nationally-representative data from the 2003 National
Assessment of Adult Literacy (NAAL) to examine the
levels of literacy and health literacy for parents. The
second paper, by Cull (et al.), will present the
experiences of a national random sample of
pediatricians related to health literacy and health
communication. The focus will be shifted in the second
half of the session to 2 different inner-city sites that have
developed and implemented programs to improve parent
and child understanding using the principles of health
literacy: 1) Dreyer et al., NYU, Health Education and
Literacy for Parents (HELP) project, and 2) Bayldon et
al., Children’s Memorial Chicago, Literacy, Education,
and Parent Participation (LEAPP) program.At the end of
the session, participants will 1) be aware of the scope of
the health literacy problem as it relates to children, 2) be
familiar with different approaches being utilized in
pediatric practices to try to improve patient
understanding, and 3) be included in the discussion of
the child-focused research questions that are in need of
future study.
● Pediatrician Experiences with Health Literacy:
National Survey Results
William Cull, Ph.D.; Teri Turner, M.D., M.P.H., M.Ed.;
Barbara Bayldon, M.D.; Mary Ann Abrams, M.D.; Lee
Sanders, M.D.; Benard Dreyer, M.D.
Presented by: William Cull, Ph.D., Director, HSR,
Research, American Academy of Pediatrics, 141
Northwest Point Blvd, Elk Grove Village, IL 60007,
Phone: (847) 434-7628, Email: wcull@aap.org
Research Objective: To describe pediatricians’ selfreported experiences with health literacy (HL), utilization
of basic and enhanced communication techniques, and
perceived barriers to effective communication during
office visits.
Study Design: In 2007, a cross-sectional survey about
health literacy and patient communication was
conducted through the American Academy of Pediatrics
(AAP) Periodic Survey of Fellows. The survey was sent
to 1605 pediatricians with a response rate of 56%.
Analyses were limited to 848 respondents in direct
patient care and past residency training. A combined
measure was created to describe pediatricians’ use of
basic communication strategies based on whether
pediatricians use more than half of 7 basic strategies
“most of the time” or “always.” A similar combined
measure was created for 7 enhanced communication
strategies; a comparison between the basic and
enhanced measures was made using a McNemar
nonparametric test for repeated measures.
Population Studied: A national, random sample of nonretired pediatricians who are U.S. members of the AAP.
Principal Findings: Eight out of every ten pediatricians
(81%) were aware of a situation in the past 12 months
where a parent had not sufficiently understood
presented health information. In addition, 44% of all
pediatricians were aware of a communication-related
error in patient care within the past 12 months.
Pediatricians overwhelmingly agreed with general
principles of health literacy such as “patient/parent
difficulties communicating with medical personnel can
lead to errors in patient care” (93%) and “ensuring
patients and parents understand the health information
given to them can improve the quality of pediatric health
care delivery” (87%). Pediatricians report they regularly
used basic communication strategies such as using
simple language (99%), repeating key information
(92%), and presenting only 2 or 3 concepts at a time
(76%). Far less often did pediatricians report using
enhanced communication techniques recommended by
HL experts such as teach back (23%) and indicating key
points on written educational materials (28%). Using the
combined measures, pediatricians were significantly
more likely to use basic strategies than enhanced
strategies (97% versus 24%, p < .001). Pediatricians
who report that their patient mix has a higher number of
parents with limited literacy skills were more likely than
other pediatricians to use the enhanced strategies (38%
versus 23%, p = .002). The top barriers to effective
communication were limited time to discuss information
(73%), volume of information (65%), and complexity of
information (64%).
Conclusions: Most pediatricians experience patient
communication problems in their practice and they agree
with health literacy principles. They, however, do not
use enhanced strategies regularly which is likely related
to limited time available to spend with each patient.
Implications: The conflict between the need to better
communicate with patients and limited time to spend
with each patient suggests a need to explore alternative
methods to improve patient communication.
● The Health Literacy of Parents in the U.S.: A
Nationally Representative Study
H. Shonna Yin, M.D., M.S.; Matthew Johnson, Ph.D.;
Alan L. Mendelsohn, M.D.; Mary Ann Abrams, M.D.,
M.P.H.; Lee M. Sanders, M.D.; Benard P. Dreyer, M.D.
Presented by: H. Shonna Yin, MD, MS, Instructor of
Pediatrics, Pediatrics, NYU School of Medicine, 550 First
Avenue, NBV-8S-4-11, New York, NY 10016, Phone:
(212) 689-0322, Email: Hsiang.Yin@nyumc.org
Research Objective: To assess the health literacy of
US parents and explore the role of health literacy in
mediating child health disparities.
Study Design: A cross-sectional study was performed
for a nationally representative sample of US parents
from the 2003 National Assessment of Adult Literacy.
Parent performance on 13 child health-related tasks was
assessed by simple weighted analyses. Logistic
regression analyses were performed to describe factors
associated with low parent health literacy, and explore
the relationship between health literacy and self-reported
child health insurance status, difficulty understanding
over-the-counter (OTC) medication labeling, and use of
food labels.
Population Studied: Over 6,100 parents (representing
72,600,098 US parents) participated.
Principal Findings: Of the 6,100 parents in the sample,
28.7% had Below Basic/ Basic health literacy. 68.4%
were unable to enter names and birthdates correctly on
a health insurance form. 65.9% were unable to calculate
the annual cost of a health insurance policy based upon
family size. 46.4% were unable to perform at least one of
two medication-related tasks. Parents with Below Basic
health literacy were more likely to have a child without
health insurance in their household (AOR 2.4;
95%CI:1.1-4.9) compared to parents with Proficient
health literacy. Parents with Below Basic health literacy
had 3.4 times the odds of reporting difficulty
understanding OTC medication labels (95%CI:1.6-7.4).
Parent health literacy was associated with nutrition label
use in unadjusted analyses but did not retain
significance in multivariate analyses. Health literacy
accounted for some of the effect of education,
racial/ethnic, immigrant status, linguistic, and incomerelated disparities.
Conclusions: A large proportion of US parents have
limited health literacy skills and are unable to perform
tasks such as completing health insurance forms.
Implications: Decreasing literacy demands on parents,
including simplification of health insurance and other
medical forms, as well as medication and food labels, is
needed in order to decrease healthcare access barriers
for children and allow for informed parent decisionmaking. Addressing low parent health literacy may
ameliorate existing child health disparities.
Funding Source(s): Pfizer Fellowship in Health Literacy
Rethinking Case Management and Care
Coordination for Pregnant Women and Children
Moderator: Anne Markus, J.D., Ph.D., M.H.S.
Saturday, June 27 ♦ 1:45 p.m.–3:15 p.m.
Panel Overview: The purpose of the panel presentation
is to provide child health researchers and other
interested individuals with the latest evidence on case
management and care coordination (CM/CC) in general
but with a special emphasis on children with special
needs so that policy solutions may be developed to
support an all-payer benefit that would be available to all
children who need it, regardless of their source of health
insurance. The panel will start with an overview and
synthesis of the literature to date, which will emphasize
the following elements: What is CM/CC? How is CM/CC
currently defined by various programs and professions?
What do we know or don’t know about the benefits of
CM/CC for pregnant women and children? The panel will
then provide the audience with examples of current
programs that rely heavily on CM/CC to provide services
to needy children, highlighting barriers, successes and
innovations. Programs highlighted include Title V
maternal and child health programs, Healthy Start for
pregnant women and infants, and the ABCD initiative.
The panel will end with a presentation of a conceptual
framework for thinking about CM as clinical and nonclinical tiers in a continuum of care from inpatient to
outpatient settings provided by a CC team made of a mix
of providers, how this framework was used to guide the
operationalization of an all-payer benefit for
reimbursement, highlighting the implications for Medicaid
and broader health care reform by providing concrete
recommendations for further action.
● Understanding Case Management and Care
Coordination: Definitions, Evidence, and Role in
Public Programs
Kay Johnson, M.P.H., M.Ed.; Sara Rosenbaum, J.D.;
Emily Jones, M.P.P.; Anne Markus, J.D., Ph.D., M.H.S.
Presented by: Kay Johnson, M.P.H., M.Ed., Research
Associate Professor, Pediatrics, Dartmouth Medical
School, 175 Red Pine Road, Hinesburg, VT 05461,
Phone: (802) 482-3005, Email:
kay.johnson@johnsongci.com
Research Objective: In public health and child health
practice, the terms care coordination and case
management (CC/CM) are used interchangeable to
describe an array of activities designed to link families to
services, avoid duplication, and improve communication
between families and providers. CC/CM includes:
assisting with completing care plans and referrals within
and outside of the health care system; and arranging for
transportation, in-home services, and a variety of other
support services. In today’s complex health system,
CC/CM helps assure optimal health care outcomes for
children in socially or medically high risk conditions.
There is great variation in the operation of CC/CM, and
services are delivered by physicians, nurses, social
works, and paraprofessional community health workers.
Some is inside provider settings and other CC/CM is
grounded in local health departments, managed care
organizations, and other system-wide entities. This
project is designed to generate policy recommendations
on CC/CM in publicly financed child health programs
including Medicaid, State Child Health Insurance
Program (SCHIP) and Title V Maternal and Child Health.
Study Design: Systematic review of the health
literature, federal law, and state public health practice.
Population Studied: Indirectly, pediatric patients with
special health care needs.
Principal Findings: A number of studies have found
CC/CM to be effective for the high-risk, low-income
families typically served by Medicaid and for children
with special health needs. Medicaid law has long
recognized case management, both as an administrative
activity and as medical assistance. Administrative
CC/CM includes activities such as assistance with
appointment scheduling or utilization review. “Targeted”
medical assistance case management is used to provide
CC/CM to specific groups (e.g., pregnant women, one
geographic area). Some restrictions to medical
assistance case management were imposed by the
Deficit Reduction Act of 2005 (DRA). (Rules proposed by
CMS appear to go beyond the intent of the DRA). But
the DRA did not alter either statutory provisions that links
Medicaid and Title V. Since the enactment of EPSDT,
state Medicaid and Title V programs have been required
to work together to assure child health. Examples from
the Title V information system illustrate relationships in
the following categories of CC/CM: medical home,
EPSDT informing and outreach, services to CSHCN,
and maternity and infant care. The relationships between
Medicaid and Title V help to finance and provide CC/CM
for children.
Conclusions: Research supports CC/CM as effective in
increasing access to necessary services for certain
children, particularly those served by Medicaid, SCHIP,
and Title V programs. Revised statutory or regulatory
language is needed to clarify Medicaid coverage and
financing for CC/CM. New legal language should
address CC/CM definition, coverage, payment, quality
performance measurement, the relationships between
Medicaid financing and public programs, and the
distinction between case management that is an intrinsic
aspect of clinical care and that which augments clinical
care.
Implications: Assuring optimal child health and
development depends upon a complex interaction of
family support, health financing, access to providers, and
other determinants of health. From a public policy
standpoint, CC/CM should be structured to support
effective linkages and interactions.
Funding Source(s): CWF
● The Care Coordination/Case Management
Experience of the Washington, DC Healthy Start
Programs
Meagan Lyon, M.P.H., C.H.E.S.; Anne Markus, J.D.,
Ph.D., M.H.S.; Ashley Foster, M.P.H.
Presented by: Meagan Lyon, M.P.H., C.H.E.S.,
Research Associate Professor, Health Policy, George
Washington University, 2021 K Street, NW, Suite 800,
Washington, DC 20006, Email: mlyon@gwu.edu
Research Objective: The public health program Healthy
Start (HS) employs hybrid case management models to
improve birth outcomes and reduce health disparities
among the low income women and infants they serve.
The home, at the end of the community setting
spectrum, is an appropriate location to manage care for
women who experience barriers to accessing servicesthose marginalized from formal health care settings and
who experience social isolation. Home visitation
programs that contribute to the development of the
maternal life course and connect families with culturally
appropriate services have been found to improve
maternal and infant health outcomes. The study sought
to understand the perceptions of HS community health
workers (CHW) about their ability to meet client needs
and the barriers they often see their high-risk, publiclyinsured clients face in accessing quality medical and
social services in DC.
Study Design: Qualitative semi-structured interviews
with CHWs employed by the two HS programs in DC.
Population Studied: DC HS employees, including
nurses and CHWs (n= 34).
Principal Findings: In DC, women in HS are insured
either by the Medicaid or the Alliance programs and
represent a small, but sentinel, percentage of all
publicly-covered pregnant women, who are typically
considered at higher risk of having undesirable birth
outcomes and could benefit from case management.
Blended case management teams along the continuum
of care deliver services- registered nurses provide
clinical care and community health workers manage the
psychosocial needs of the women within the context of
their home, elements all found to be effective in
improving maternal and child health outcomes. A key
finding among those providing case management
services in DC was that despite being able to
successfully schedule/refer clients to pre- and postnatal
care, they were unable to ensure clients have sufficient
transportation for their visits, or that they received
appropriate language services once at the hospital/clinic.
Conclusions: Public health programs such as DC HS
are an example of a hybrid case management model in
a community setting that assists high risk pregnant
women with their complex medical and social needs.
Our findings about services covered but not provided by
Medicaid and Alliance are examples of gaps in
appropriate care for high-risk, pregnant women and their
infants that can be modified through improvements in the
case management and care coordination functions of all
of these programs.
Implications: Improved coordination between HS and
Medicaid/Alliance, particularly between HS CHWs and
the managed care plans participating in
Medicaid/Alliance and their case managers, would
increase pregnant and postpartum women’s ability to
receive medically necessary prenatal and postnatal care,
transportation and language services and contribute to
the improvement of perinatal outcomes and the
reduction of health disparities in DC.
● The Screening/Referral/Care
Coordination/Feedback Loop of Iowa’s First Five
Program
Sharon Silow-Carroll, M.B.A., M.S.W.
Presented by: Sharon Silow-Carroll, M.B.A., M.S.W.,
Principal, Health Management Associates, 1133 Avenue
of the Americas, Suite 2810, New York, NY 10036,
Phone: (212) 575-5929 x523, Email:
ssilowcarroll@healthmanagement.com
Research Objective: The Iowa Department of Public
Health’s First Five Healthy Mental Development Initiative
involves a public-private partnership based on
physicians using a standardized screening and referral
process for children and care givers at risk for
physical/emotional issues such as family stress and
depression, developmental delays, etc. The physician
provides a referral to a CM at a community health
center/agency who facilitates the care/referrals for the
family, as well as provides an additional assessment to
see if there are any additional social issues. For
Medicaid beneficiaries, most referrals are covered under
EPSDT; for those with private insurance, the program
covers the cost; for those without insurance, Title V
helps cover costs. New federal "targeted case
management" definitions might put funding for some
care coordination services in jeopardy. The study sought
to understand the development, implementation, and
ongoing operations of this program, and the lessons
learned that may help administrators, advocates, and
policymakers interested in developing an effective care
coordination program that assists both families and
practitioners.
Study Design: Qualitative semi-structured interviews
with state and program administrators, coordinators, and
evaluators in Iowa.
Population Studied: First Five administrators,
employees, and evaluators (n= 6).
Principal Findings: Early First Five experience
indicates that families identified through the program
have a range of unmet needs: each physician referral
results in an average of three to five follow-up referrals
for services. Further, there have been anticipated issues
with getting buy-in and participation from physicians- a
physician consultant (an MD) has been useful in
explaining the utility of a standard screening tool,
encouraging an expanded view of health (including
family and mental health issues), underscoring the
value of "comprehensive care coordination", and
bridging the public and private systems. These
partnerships are complex-they involve physicians,
community health centers/agencies, support services
like home visiting programs and county health
departments, and the CM/CC is responsible for
maintaining relationships with the community resources
that they refer clients to (through "resource books,"
communication, etc).
Conclusions: The findings speak to the complexity of
the family issues and the need for comprehensive care
coordination, beyond efforts typically provided by
primary care practitioners, to assist families at risk.
Bringing practitioners and medical office staff on board
requires ongoing education on healthy development and
use of screening and referral tools. Once involved,
pediatric practices tend to be grateful for assistance in
coordinating care and for feedback about their patients.
Implications: There are models that are successfully
bridging public and private health care systems to
improve early detection of social–emotional delays and
prevention of mental health problems among young
children and their families. With adequate and
sustainable funding, there is potential to replicate this
model in other regions.
Funding Source(s): CWF
● The Conceptual and Legal Bases for Case
Management Services for Child Health and
Development Reimbursed by Medicaid and Other
Payers
Anne Markus, J.D., Ph.D., M.H.S.; Sara Rosenbaum,
J.D.; Emily Jones, M.P.P.; Kay Johnson, M.P.H., M.Ed.
Presented by: Anne Markus, J.D., Ph.D., M.H.S.,
Associate Research Professor, Health Policy, George
Washington University, 2021 K Street, NW, Suite 800,
Washington, DC 20006, Email: armarkus@gwu.edu
Research Objective: The concept of case management
has been part of the Medicaid statute since the law’s
1965 enactment. Recent attention to certain “targeted
case management” amendments enacted in 1986 and
revised in 2005 have tended to occupy center stage, but
where children are concerned, numerous provisions of
law become relevant and need to be considered in
designing and operating case management services in a
developmental child health context. The purpose of this
policy and legal analysis is to describe these provisions,
outline an evidence-based and theoretically-based
conceptual framework to think about CM as clinical and
non-clinical tiers in a continuum of care from inpatient to
outpatient settings provided by a CC team made of a mix
of providers, and delineate an all-payer reimbursement
scheme for these types of services.
Study Design: Policy and legal analysis of Medicaid law
and implications for reimbursement reform, using a
conceptual framework to guide the analysis.
Population Studied: Indirectly, pediatric patients with
complex social and health care needs.
Principal Findings: Where case management to
achieve developmental child health is concerned, the
Medicaid statute and regulations support the
development of comprehensive interventions aimed at
assuring the appropriate use of necessary Medicaidfinanced care and coordinating with other types of care
and services that relate to the healthy development of
children. In certain respects, the authority and duty of
states to manage the health of enrolled children is
explicit, in others, the Secretary is explicitly empowered
to make findings regarding the scope of permissible
activities.
Conclusions: This analysis shows that the legal basis
to support comprehensive case management and care
coordination services already exists in Medicaid law. It
also concludes that the spectrum of case management
needs to be tiered to need and health status and to
provider type (highly skilled providers to less skilled
providers) and care setting (inpatient clinical settings to
outpatient home setting). Finally, from a reimbursement
perspective, case management can be done as
administrative or medical assistance.
Implications: No one size fits all to creating legal
authority exists since states and other purchasers may
want to manage differently or use a combination of
reimbursement schemes for both administrative and
medical assistance. Case management and care
coordination entail a range of services that are both
covered and excluded by Medicaid and other payers but
can be/are offered through public health programs and
public-private partnerships. Payers and
programs/partnerships will need to clearly delineate the
two “systems” and how they will efficiently communicate
and handle referrals back and forth so that children can
meet their health and developmental needs.
Funding Source(s): CWF
Starting Right: Innovative Strategies for Pediatric
Obesity in the South Bronx
Moderator: Monique Cuffee-Archibold, M.P.H.
Saturday, June 27 ♦ 1:45 p.m.–3:15 p.m.
Panel Overview: Childhood obesity is now an epidemic
problem among inner-city African-American and Latino
children. At the South Bronx Health Center for Children
and Families (SBHCCF), an estimated 55% of pediatric
patients age 6-19 are overweight or obese (BMI => 85th
percentile). Starting Right is a multidisciplinary pediatric
obesity program at the SBHCCF focused on creating
innovative, culturally appropriate methods of engaging
with this inner city community around obesity and
healthy lifestyles. Efforts include screening for
overweight and associated health risk factors; familycentered counseling by a bilingual nutritionist in the
primary care setting; community partnerships and
legislative advocacy; and a health and fitness group for
overweight and obese youth. Group models of care
include Centering Pregnancy and Centering Parenting,
which replace traditional prenatal or well-infant solo visits
with group visits that allow more time for nutrition
education and other anticipatory guidance, as well as
promoting social support and cohesion for pregnant
women and new parents participating in the groups.
Qualitative research using focus groups has explored
parents’ and adolescent patients’ attitudes regarding
obesity and identified key barriers to change. Results
from the health and fitness group have shown healthy
behavior changes reported by youth and their parents,
as well as a statistically significant decrease in BMI zscore.
● Evaluation of a Screening Algorithm for Pediatric
Obesity and Diabetes Risk
Marian Larkin, M.D.; Jo Applebaum, M.P.H.; Ariel
Sarmiento, M.P.H.; Sandra Goldsmith, M.S., R.D.;
Sandra Arevalo, M.P.H., R.D.; Alan Shapiro, M.D.
Presented by: Marian Larkin, M.D., Pediatrician, South
Bronx Health Center for Children & Families, 871
Prospect Avenue, Bronx, NY 10459, Phone: (718) 9910605, Email: mlarkin@montefiore.org
Research Objective: To assess how a pediatric obesity
clinical algorithm is being used in clinical practice at a
community health center in the South Bronx.
Study Design: A retrospective chart review was
performed using a random sample of 200 patients ages
10-19 who had a well-child visit during the first half of
2008. Charts were examined for documentation of the
following: screening for overweight/obesity using BMI
percentile, risk factors and lab screening for type 2
diabetes mellitus (T2DM), and referral to the nutritionist.
Use of a screening form (the Starting Right or SR form)
specially designed to prompt providers to document risk
factors and referrals was also examined.
Population Studied: The South Bronx Health Center for
Children & Families serves a patient population that is
approximately 68% Latino and 28% African American,
with 67% at or below the federal poverty level, 65%
public housing residents, and 81% insured by Medicaid
or uninsured.
Principal Findings: Of the 178 patients included in the
final analysis, 99.4% (177) had BMI percentile recorded
at their annual checkup. Of the 177 patients screened,
48% (85) were overweight or obese (BMI => 85th %).
The SR form was in the chart for 74.1% (63) of these
patients, all of whom had at least one T2DM risk factor
documented. Of these, 98.3% were noted to be of highrisk race or ethnicity, 68.4% had a family history of
diabetes, 47.1% had acanthosis nigricans, 28.6% had a
history of dyslipidemia, 36.5% had elevated blood
pressure, and none had polycystic ovary syndrome. For
those patients with a SR form, 76.2% (48) had at least
two risk factors documented, and 79.2% (38) of these
patients were subsequently screened for T2DM with a
fasting glucose as recommended by the American
Diabetes Association. A nutrition referral was also
documented for 62.4% (53) of the overweight and obese
patients identified.
Conclusions: The rate of annual screening for pediatric
overweight/obesity using BMI percentile was very high
(more than 99%). Use of a screening form for T2DM risk
factors was somewhat lower (at 74%), but data from the
forms indicate that all of these patients had at least one
risk factor for T2DM. When the form was used, T2DM
screening was indicated for three-quarters of the
patients, and nearly 80% of that group had a fasting
glucose performed. The rate of documented nutrition
referral for these patients was somewhat lower but still
close to two-thirds.
Implications: A standardized clinical algorithm using a
screening form is associated with high rates of screening
for pediatric overweight/obesity and T2DM risk in a
community health center with a high-risk population.
Funding Source(s): CDC
● Adolescent and Parent Attitudes about Obesity
and Behavior Change in the South Bronx
Sandra Goldsmith, M.S., R.D.; Jo Applebaum, M.P.H.,
C.P.H.; Marian Larkin, M.D.; Ariel Sarmiento, M.P.H.,
C.P.H.; Sandra Arevalo, R.D., M.P.H.; Alan Shapiro,
M.D.
Presented by: Sandra Goldsmith, M.S., R.D., Director of
Nutrition Services, Community Pediatric Programs, 853
Longwood Avenue, Bronx, NY 10459, Phone: (718)
588-4460, Email: sgoldsmi@montefiore.org
Research Objective: To explore adolescent and parent
attitudes about obesity and behavior change to enhance
provider-patient communication and inform program
development.
Study Design; Six focus groups (4 English, 2 Spanish)
with 33 participants (11 overweight adolescents, 22
parents) were conducted to explore obesity, nutrition and
exercise-related topics. Focus groups were transcribed,
coded by multiple researchers using qualitative analysis
software and analyzed using a social ecology
framework.
Population Studied: The community served by the
South Bronx Health Center for Children and Families
has among the highest rates of obesity in NYC.
SBHCCF created Starting Right, a multi-component
pediatric obesity program integrated into its primary care
practice.
Principal Findings: Several themes emerged: 1.
Obesity and nutrition are emotionally charged issues for
all participants: parents feel guilty limiting/changing kids’
diets; teens are concerned with body image and selfesteem. 2. Health risks of obesity are not a primary
motivator for behavior change except when family or
friends develop obesity-related conditions. 3. Finances,
time, and environment are major barriers to healthy
changes in diet and activity. 4. Intensive provider
involvement and detailed guidance are important
motivators for behavior change.
Conclusions: Emotional, financial and environmental
factors all impact adolescents’ and families’ ability to
make changes in lifestyle. Long-term health risks have
limited relevance for adolescent participants. Health
risks are more likely to foster change when a family
member is affected by obesity-related disease.
Children’s preferences often drive family food choices.
Access to healthy foods and opportunity for physical
activity are lacking in schools and the local community.
Implications: Families look to providers for motivation
and education to make healthy behavior changes. As
practitioners, it’s important to provide intensive follow-up.
Providers should also advocate for public policy changes
that will improve the environment of the community
served.
patients and their families has generated about 20
encounters at each meeting for a total of 320 encounters
per year. Monthly cooking demonstrations in the waiting
area reach more than 250 patients each year.
Conclusions: Group nutrition education is a novel and
promising approach to promoting healthy eating and
physical activity in an underserved urban community.
Implications: Combining group visits with nutrition
education is an innovative approach that allows the
nutritionist to reach increased numbers of patients to
prevent and treat obesity.
● Group Nutrition Education: An Innovative
Approach to Combating Obesity
Sandra Arevalo, R.D., M.P.H.; Sandra Goldsmith, M.S.,
R.D.; Barbara Hackley, C.N.M.; Hildred Machuca, D.O.;
Ariel Sarmiento, M.P.H., C.P.H.; Alan Shapiro, M.D.
Presented by: Laura Kaiser, R.D., Nutritionist, Nutrition,
New York Children's Health Project, 853 Longwood
Avenue, Bronx, NY 10459, Phone: (718) 991-0605,
Email: lkaiser@montefiore.org
Presented by: Sandra Arevalo, R.D., M.P.H., Nutrition
Coordinator, Nutrition, South Bronx Health Center for
Children & Families, 871 Prospect Avenue, Bronx, NY
10459, Phone: (718) 991-0605, Email:
sarevalo@montefiore.org
Research Objective: To describe innovative models of
group care that promote healthy eating and physical
activity throughout the life span.
Study Design: At the South Bronx Health Center for
Children and Families (SBHCCF), nutrition education
has been incorporated into various models of group
care, including groups for prenatal and well-baby care,
weight loss for overweight youth, and diabetes education
and support groups. Fun and interactive cooking
demonstrations, food tasting, supermarket scavenger
hunts, and other activities encourage behavior change
using resources found in the community.
Population Studied: The SBHCCF is a community
health center located in one of the most underserved
areas of New York City. Most patients are of Latino
(68%) or African-American (27%) descent and face
limited access to financial resources, health care, fresh
produce and other healthy food options, and community
resources for physical activity.
Principal Findings: Hundreds of patients and
community members have participated in group nutrition
education at SBHCCF since 2005. More than 200
women have participated in Centering Pregnancy group
prenatal care. Fifteen families have attended Centering
Parenting groups for babies from birth to 18 months and
their families since 2007. The Health and Fitness Group
has reached 102 overweight youth ages 10-14 and their
parents since 2005. The Food and Fitness Team has
reached more than 100 children ages 5-9 at a local
afterschool program. The POWER group for diabetic
● Prevention and Treatment of Overweight and
Obesity in Homeless Children
Laura Kaiser, R.D.; Sandra Goldsmith, M.S., R.D.; Jo
Applebaum, M.P.H., C.P.H.; Ariel Sarmiento, M.P.H.,
C.P.H.; Alan Shapiro, M.D.
Research Objective: To determine the prevalence of
overweight and obesity among the homeless children
served by the New York Children’s Health Project and to
design interventions that address this issue.
Study Design; Cross-sectional prevalence study of a
random sample of 100 patients age 10 – 19 years with a
healthcare maintenance visit during 2008. Data were
extracted from an electronic health record.
Population Studied: The number of homeless families
in New York City (NYC) is at its highest point in 25
years. In November 2008, 15,800 homeless children
were sleeping in NYC shelters. The New York Children’s
Health Project (NYCHP) is a mobile medical program
that delivers critically-needed healthcare to thousands of
homeless families. NYCHP serves a patient population
that is 51% Black/African American and 43% Hispanic.
Nearly all patients live at or below 100% of the poverty
level.
Principal Findings: Review of a random sample of 100
homeless pediatric patients at NYCHP found that 48% of
children 10 – 19 years with a documented BMI percentile
were overweight or obese; 16% were overweight and
32% were obese. Based on these findings, NYCHP
implemented the Starting Right Initiative, a pediatric
obesity program that focuses on prevention, early
identification, and treatment of childhood overweight to
prevent associated morbidities. It includes screening for
overweight and type 2 diabetes mellitus risk factors,
family-centered nutrition counseling, and group nutrition
education. Given the transient nature of this population,
we adapted the Starting Right model to focus on
strategies patients can use while in the shelter system
and beyond. Additionally, we developed and piloted
CHEFFs (Cooking, Healthy Eating, Fitness and Fun), an
interactive group nutrition and fitness program, which
partners with shelter after-school programs and focuses
on healthy eating, physical activity, and media literacy.
Conclusions: Obesity is a significant issue among
homeless pediatric patients in NYC. Families face many
barriers to healthy eating and adequate exercise
including limited access to healthy foods, safe spaces to
play, time-management skills, financial barriers, and
suboptimal cooking facilities. The Starting Right Initiative
addresses the issue of obesity while also providing
continuity of care as homeless patients transition to
housed environments.
Implications: When developing obesity interventions for
the homeless population, it is important to design
programs that address the transient nature of this
population. While chronic health issues such as obesity
may be seen as less than urgent for homeless patients,
it is important to address them in a way that empowers
families to make healthy lifestyle changes and advocate
for their medical needs after leaving the shelter system.