Confessions of a Square Peg

Monitoring Duration of Coverage in Medicaid and CHIP to Assess Program Performance and Quality

Elimination of racial and ethnic disparities in health has become a major national goal. The State Children's Health Insurance Program (SCHIP) has the potential to reduce disparities among the children who enroll if they exhibit the same disparities that have been documented in previous studies of low-income children. To determine the potential impact of SCHIP on racial and ethnic disparities, it is critical to assess baseline levels of health disparities among children enrolling in SCHIP. To use data from the Child Health Insurance Research Initiative (CHIRI) to 1) describe the sociodemographic profile of new enrollees in SCHIP in Alabama, Florida, Kansas, and New York; 2) determine if there were differences in health insurance and health care experiences among white, black, and Hispanic SCHIP enrollees before enrollment in SCHIP; and 3) explore whether race or ethnicity, controlled for other factors, affected pre-SCHIP access to health coverage and health care. SCHIP programs in Alabama, Florida, Kansas, and New York, which together include 26% of SCHIP enrollees nationwide. Telephone interview (mailed survey in Alabama) about the child's health, health insurance, and health care experiences conducted shortly after SCHIP enrollment to assess experience during the time period before SCHIP. New SCHIP enrollees (0-17.9 years old in Alabama, Kansas, and New York and 11.5-17.9 years old in Florida). Stratified sampling was performed in Kansas and New York, with results weighted to reflect statewide populations of new SCHIP enrollees. Sociodemographic characteristics including income, education, employment, and other characteristics of the child and the family, race and ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic [any race]), prior health insurance, health care access and utilization, and health status. Bivariate analyses were used to compare baseline measures upon enrollment for white, black, and Hispanic SCHIP enrollees. Multivariate analyses were performed to assess health status and health care access measures (prior insurance, presence of a usual source of care (USC), and use of preventive care), controlling for demographic factors described above. Weighted analyses (where appropriate) were performed by using SPSS, STATA, or SUDAAN. Racial and ethnic composition varied across the SCHIP cohorts studied, with black and Hispanic children comprising the following proportion of enrollees, respectively: Alabama, 33% and <1%; Florida, 16% and 26%; Kansas, 12% and 15%; and New York, 24% and 36%. Black and Hispanic children were more likely to reside in single-parent and lower-income families. With some variation by state, children from minority groups were more likely to report poorer health status than were white children. Relative to white children, children from minority groups in Florida and New York were more likely to have been uninsured for the entire year before SCHIP enrollment. In all states, children from minority groups who had prior coverage were more likely to have previously been enrolled in Medicaid than in private health insurance and were less likely to have had employer-sponsored coverage compared with white children. Except in Alabama, there was a difference in having a USC, with children from minority groups less likely to have had a USC before SCHIP enrollment compared with white children. No consistent pattern of health care utilization before SCHIP was noted across states with respect to race or ethnicity. Findings from multivariate analyses, controlling for sociodemographic factors, generally confirmed that black and Hispanic children were more likely to have lacked insurance or a USC before enrollment in SCHIP and to have poorer health status compared with white children. SCHIP is enrolling substantial numbers of racial and ethnic minority children. There are baseline racial and ethnic disparities among new enrollees in SCHIP, with black and Hispanic children faring worse than white children on many sociodemographic and health system measures, and there are differences among states in the prevalence and magnitude of these disparities. After controlling for sociodemographic factors, these disparities persisted. IMPLICATIONS FOR MONITORING AND IMPROVING SCHIP: SCHIP has the potential to play a critical role in efforts to eliminate racial and ethnic disparities in health among the children it serves. However, study findings indicate that programmatic efforts are necessary to ensure that disparities are not perpetuated. Program effectiveness and outcomes should be monitored by race and ethnicity to ensure equity in access, use, and outcomes across all racial and ethnic groups. Assessing the health characteristics and needs of new SCHIP enrollees can provide a benchmark for evaluating the program's impact on eliminating racial and ethnic disparities in health and inform service delivery enhancements.

A major provision of the Balanced Budget Act of 1997 established the State Children's Health Insurance Program (Title XXI of the Social Security Act). This program is a historic milestone in the financing of health care for children. Not since the enactment of Medicaid has there been a greater investment in children's health care. Title XXI does not create universal coverage for all children, but this program does offer an unprecedented opportunity to expand insurance ot a large portion of uninsured children. Title XXI of the Social Security Act makes >$40 billion in federal grants available to states over the next 10 years to provide health insurance coverage, including Medicaid. However, states mus contribute a defined share of funds to obtain federal matching funds. The legislation gives great flexibility to states in designing and implementing their programs, and it is critical that they do this in a timely manner. If states fail to use all State Children's Health Insurance Program funds available, it is possible that future federal funding will be reduced. If this happens, a major opportunity to improve health insurance coverage of America's children will be diminished.

BackgroundThe Taliban takeover in August 2021 brought global economic sanctions, economic collapse, and draconian restrictions on women’s freedom of movement, work, political participation, and education. This study examined Afghan health workers’ experiences and perceptions of availability and quality of maternal and child health care since then.MethodsWe conducted a survey, using a convenience sample, of health workers from urban, semi-rural, and rural public and private clinics and hospitals across the 34 provinces, covering changes in working conditions, safety, health care access and quality, maternal and infant mortality as well as perceptions about the future of maternal and child health and health care. Interviews were conducted with a subsample of health workers to further explore their perceptions of changes in working conditions, quality of care, and health outcomes since the Taliban takeover.Results131 Afghan practicing health care workers completed the survey. The majority were women (80%) working in facilities located in urban areas. Most female health workers (73.3%) reported that they have not always been safe when going to and from work; 81% because of harassment by the Taliban when they did not have male accompaniment. Almost half of the respondents (42.9%) reported a decrease in availability of maternal and child care and 43.8% stated that conditions for providing care were “worse” or “much worse” than before. Almost one-third (30.2%) indicated that changed working conditions negatively impacted their ability to provide quality care, and 26.2% reported an increase in obstetric and newborn complications. Health workers also reported (38.1% )an increase in sick child needs and an increase in child malnutrition (57.1%0. 57.1% reported decreases in work attendance and 78.6% a decrease in morale and motivation. Qualitative interviews (n = 10) of a subsample of survey participants expanded on these findings.ConclusionThe combination of economic collapse, lack of sustained donor support for health care and Taliban interference with human rights has severely compromised access and quality of maternal and child health care. Strong and concerted international pressure on the Taliban to respect women and children rights to essential health service is critical for the future of the Afghan population.

In April2023, with the "unwinding" of the Families First Coronavirus Response Act (FFCRA) continuous enrollment provisions in Medicaid, states were permitted to commence redetermination and disenrollment procedures for Medicaid beneficiaries. Using Centers for Medicare and Medicaid Services monthly state enrollment data for forty-nine states and Washington, D.C., from the period January2021-December2023, we examined changes in children's Medicaid and Children's Health Insurance Program (CHIP) coverage during the Medicaid unwinding, both overall and by whether states had previous twelve-month continuous eligibility policies for children and by the structure of states' programs for CHIP. We found substantially lower Medicaid and CHIP enrollment among children during the unwinding than during the FFCRA period, with lower levels of coverage declines among children in states that had previous twelve-month continuous eligibility policies and states with a program structure of separate CHIP or Medicaid expansion CHIP, rather than combination CHIP. These findings highlight the consequences of the FFCRA unwinding for children's Medicaid and CHIP enrollment, as well as potential state health policies that can promote coverage continuity and prevent further coverage loss for children moving forward.

To test social-cognitive influences on parent decision-making processes related to children's health care use. Eighty-seven primary caretakers of children ages 4 to 9 years completed measures of child health and behavior, parent functioning, and social-cognitive factors related to parenting and health care use. Primary care use was obtained from the children's primary care physician(s) for the 2 years prior to recruitment. Social-cognitive variables accounted for 13.2% of the variance in primary health care use, above and beyond the influence of child health status and psychosocial variables. The best predictive model, accounting for 29.8% of the variance in primary care use, included the interaction between parental stress and self-efficacy to cope with parenting demands, child behavior problems, self-efficacy for accessing physician assistance, medication use, and parent health care use. Results documented the relationship between self-efficacy and parent stress in decision making about pediatric primary care use. Social-cognitive theory provides a new perspective for evaluating factors that influence health care use.

Background:&#13;\n&#13;\nChildren with cerebral palsy often have numerous health care needs and require complex multidisciplinary health care. Holistic family centred care that is inclusive of the viewpoints of parents and children is regarded as best practice for health care service delivery for children with cerebral palsy and their families. However, dissatisfaction with care is an ongoing issue for parents of children with cerebral palsy, despite theoretical changes to health care service delivery practices toward a more family centred approach. In addition, current guidelines and standards of care for this population have been developed by health professionals without, or with little, involvement of parents. Parents' perceptions of their child's health care needs may differ from that of health professionals. If the existing guidelines and standards do not reflect the needs of the child and the family due to the lack of parental input, this may be part of the reason why parents of children with cerebral palsy continue to be dissatisfied with their child's care. No previous researchers have investigated how parents of children with cerebral palsy experience health care for their child.&#13;\n&#13;\nAim:&#13;\n&#13;\nThe aim of this study is to explore parents' experiences of health care for their children with cerebral palsy living in a regional area of Queensland, Australia. From this exploration, the aim of this study is to develop a conceptual model that explains parents' experiences and can be used to inform future clinical health care service delivery practices and guidelines and standards of care for children with cerebral palsy and their families.&#13;\n&#13;\nMethods:&#13;\n&#13;\nThis study is a qualitative exploratory study using grounded theory methodology, and is underpinned by a relativist approach and social constructivist viewpoint. The study design was selected based on the purposes and clinical context of the study, as well as my positioning as a health professional with a background in physiotherapy who has provided health care to children with cerebral palsy and their families. Participants were parents of children with cerebral palsy living in a regional area of Queensland, Australia, and were recruited using convenience and theoretical sampling. Data collection and analysis was conducted concurrently following the grounded theory method of constant comparative analysis. Two focus groups and eight in-depth interviews were conducted with eleven parents over a ten month period. Data was analysed using systematic grounded theory methods including coding, memoing, sorting and diagramming. A conceptual model was developed to explain parents' experiences. The final conceptual model was compared and contrasted with relevant literature, enabling identification of how the study findings contributed to current understandings of health care service delivery for children with cerebral palsy and their families.&#13;\n&#13;\nResults:&#13;\n&#13;\nParents living in a regional Queensland area experience health care for their children with cerebral palsy as an constant but evolving process of "making the most of their body and their life". The core category of "making the most of their body and their life" is how parents' experience the overall purpose for health care in the life of their child and family. Key categories of the conceptual model that represent important aspects of care for parents of children with cerebral palsy include learning as you go, navigating the systems, meeting needs through partnership, being empowered or disempowered, and finding a balance. These categories resonate with and support key principals of current approaches to health care service delivery for this population including family centred care, the concept of a partnership between parents and their children's health care providers, and empowerment. However, the findings of the study also identify new understandings of parents' experiences of health care for their children with cerebral palsy. These understandings include the temporal nature of the needs of the child and family evolving over time, the concept of being empowered or disempowered through the interactive processes of health care, the importance of having a community or network of supports to receiving information and guidance, and the importance of the attitudes and values of health care workers and services to parents' experiences of their child's health care.&#13;\n&#13;\nConclusion:&#13;\n&#13;\nHealth care workers and services should take into consideration parents' experiences of health care for their children with cerebral palsy and the impact it has on them, their child and their families. Modifications to health care service delivery practices to better reflect parents' experiences of health care and important aspects of care, as well as the development of new models of care that incorporate the conceptual model developed from this study, could potentially assist in improving parental satisfaction with care for their children with cerebral palsy. Further research exploring children's experiences of health care, as well as comparison of experiences in different geographical areas, with different models of service delivery, and with health professionals and policy makers, is required to develop a broader theory around health care service delivery for children with cerebral palsy and their families.

Adolescent Health Measurement—A Necessary Step Toward Achieving Global Goals

This commentary explores maternal and child health (MCH) care within the context of the Seventh-day Adventist (SDA) faith, where health is viewed as a spiritual obligation. Rooted in the Adventist “health message,” maternal care emphasizes holistic wellness, preventive practices, and spiritual resilience. Faith-informed behaviors—such as vegetarianism, rest through Sabbath observance, and abstinence from harmful substances—contribute to favorable pregnancy outcomes and mental well-being. Adventist communities and institutions, like Loma Linda University Medical Center, integrate modern medical care with faith-based values, offering services such as nutritional counseling, childbirth education, and spiritual support. Emotional stability is further strengthened through prayer, church rituals, and pastoral care. While tensions may arise between religious beliefs and some public health interventions, Adventist models generally align with global health goals through their emphasis on prevention, community care, and whole-person healing. This perspective underscores the potential of faith-based frameworks to complement scientific approaches in maternal and child health care.

Enrollment success in state children's health insurance program after free clinic referral

Ultrasound in Obstetrics & GynecologyVolume 19, Issue 6 p. 627-629 Letter to the EditorFree Access Prenatal diagnosis of fetal face hemangioma in a case of Kasabach–Merritt syndrome M. Respondek-Liberska, Corresponding Author M. Respondek-Liberska [email protected] Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandDepartment for Diagnosis of Congenital Malformations, Institute ‘Polish Mother's Memorial Hospital’, Rzgowska 281/289, 93–345 Lodz, PolandSearch for more papers by this authorK. Janiak, K. Janiak Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandSearch for more papers by this authorA. Jakubek, A. Jakubek Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandSearch for more papers by this authorI. Maroszyñska, I. Maroszyñska Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandSearch for more papers by this authorB. Lipka, B. Lipka Institute ‘Child's Health Center Memorial Hospital’, Warsaw, PolandSearch for more papers by this authorB. Dembowska, B. Dembowska Institute ‘Child's Health Center Memorial Hospital’, Warsaw, PolandSearch for more papers by this authorB. Milewska-Bobula, B. Milewska-Bobula Institute ‘Child's Health Center Memorial Hospital’, Warsaw, PolandSearch for more papers by this authorD. Perek, D. Perek Institute ‘Child's Health Center Memorial Hospital’, Warsaw, PolandSearch for more papers by this authorJ. Wilczyñski, J. Wilczyñski Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandSearch for more papers by this author M. Respondek-Liberska, Corresponding Author M. Respondek-Liberska [email protected] Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandDepartment for Diagnosis of Congenital Malformations, Institute ‘Polish Mother's Memorial Hospital’, Rzgowska 281/289, 93–345 Lodz, PolandSearch for more papers by this authorK. Janiak, K. Janiak Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandSearch for more papers by this authorA. Jakubek, A. Jakubek Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandSearch for more papers by this authorI. Maroszyñska, I. Maroszyñska Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandSearch for more papers by this authorB. Lipka, B. Lipka Institute ‘Child's Health Center Memorial Hospital’, Warsaw, PolandSearch for more papers by this authorB. Dembowska, B. Dembowska Institute ‘Child's Health Center Memorial Hospital’, Warsaw, PolandSearch for more papers by this authorB. Milewska-Bobula, B. Milewska-Bobula Institute ‘Child's Health Center Memorial Hospital’, Warsaw, PolandSearch for more papers by this authorD. Perek, D. Perek Institute ‘Child's Health Center Memorial Hospital’, Warsaw, PolandSearch for more papers by this authorJ. Wilczyñski, J. Wilczyñski Institute ‘Polish Mother's Memorial Hospital’, Lodz, PolandSearch for more papers by this author First published: 12 December 2002 https://doi.org/10.1046/j.1469-0705.2002.00731_3.xCitations: 15AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume19, Issue6June 2002Pages 627-629 RelatedInformation

BackgroundHealth care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers.MethodsWe conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women’s pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches.ResultsForty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care.ConclusionWe found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.

Staff in Swedish child health care today feel a gap between policy and practice. By revealing the main lines in the development of child health care, we hoped to achieve a better understanding of the current trends and problems in today's Swedish child health care. A selection of official documents about the development of child health care during the period 1930-2000 was studied with the aid of discourse analysis. Four discourses were identified, which serve as a foundation for a periodization of the development of child health care. In the first period the main task of child health care, alongside checking on the development of the child, was to inform and educate the mothers. During the second period health supervision became the crucial task, to identify risks and discover abnormalities and disabilities. The third period focused on the discussion concerning the identification of health-related and social 'risk groups', and the work of child health care was increasingly geared to supervision of the parents' care of their children. Parents were to be given support so that they could cope with their difficulties by themselves. During the current period child health care is increasingly expected to direct its work towards the child's surroundings and the family as a whole and is now explicitly defined as an institution that should strengthen parents' self-esteem and competence. The level of responsibility for the child's health changed gradually during the different periods, from public responsibility to parental responsibility. The focus of efforts in child health care was changed from being general in the first and second periods to general and selective in period three, and then gradually becoming selective again in period four. While control of the child's physical health was central during the first two periods, psychosocial health came into focus in the last two, along with the importance of supporting the parents to enable them to handle their difficulties by themselves. We noted that it was difficult to translate policy recommendations into practice. One reason was the shifting focus in child health care from the child's physical health to psychosocial problems which in itself meant a shift from descriptions of concrete and well-defined duties to more abstract and general descriptions of tasks which are by definition open to interpretation. Another reason for the noted difficulty was the transition from unambiguously described measures in terms of paternalistic regulation to more participatory and at the same time more expansive definitions of roles and responsibilities.

Management of child health care can be negatively affected by incomplete recording, low data quality, and lack of data integration of health management information systems to support decision making and public health program needs. Given the importance of identifying key determinants of child health via capturing and integrating accurate and high-quality information, we aim to address this gap through the development and testing requirements for an integrated child health information system. A five-phase design thinking approach including empathizing, defining, ideation, prototyping, and testing was applied. We employed observations and interviews with the health workers at the primary health care network to identify end-users' challenges and needs using tools in human-centered design and focus group discussion. Then, a potential solution to the identified problems was developed as an integrated maternal and child health information system (IMCHIS) prototype and tested using Software Quality Requirements and Evaluation Model (SQuaRE) ISO/IEC 25000. IMCHIS was developed as a web-based system with 74 data elements and seven maternal and child health care requirements. The requirements of "child disease" with weight (0.26), "child nutrition" with weight (0.20), and "prenatal care" with weight (0.16) acquired the maximum weight coefficient. In the testing phase, the highest score with the weight coefficient of 0.48 and 0.73 was attributed to efficiency and functionality characteristics, focusing on software capability to fulfill the tasks that meet users' needs. Implementing a successful child health care system integrates both maternal and child health care information systems to track the effect of maternal conditions on child health and support managing performance and optimizing service delivery. The highest quality score of IMCHIS in efficiency and functionality characteristics confirms that it owns the capability to identify key determinants of child health.

Mental Health Care Reforms in Latin America: Child and Adolescent Mental Health Services in Mexico