The Effect of a Parenting Education Program on the Use of Preventive Pediatric Health Care Services Among Low-Income, Minority Mothers: A Randomized, Controlled Study
From the Community of Health and Pediatrics/Obstetrics and Gynecology, George Washington University Medical Center, Washington, District of Columbia
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ABSTRACT |
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Objective. To determine if a community-based intervention program focusing on parenting education will have an impact on preventive health care utilization behaviors among low-income, minority mothers in Washington, DC.
Design. The experimental design was a randomized, controlled study in which 286 mother-infant dyads were assigned to either the standard social services (control) group or to the intervention group. Women and their newborn infants were recruited during the immediate postpartum period in 4 Washington, DC, hospital sites from April 1995 to April 1997. The year-long multicomponent intervention included home visits and hospital-based group sessions in addition to the standard social services available at the hospital sites. A total of 286 postpartum women with inadequate prenatal care were assigned randomly to the control or the intervention group. Women and their infants were followed for 1 full year. Outcome measures included usage of preventive health care services including well care infant visits and adherence to immunization schedules during the first year of the infant’s life.
Results. Infants in the intervention group initiated well care at an earlier age than controls (by 6 weeks, 62.5% vs 50% had received their first well infant visit). Infants in the intervention group had more frequent well visits (by 12 months of age, 3.5 vs 2.7 visits). Multivariate analyses showed infants in the intervention group to be more likely to complete their scheduled immunizations (by 9 months, odds ratio = 2.2, 95% confidence interval: 1.09–4.53). Those in the intervention group with more frequent contacts (30+ visits) with study personnel were most likely to have followed age-appropriate immunization schedules when compared with controls (at 9 months odds ratio = 3.63, 95% confidence interval: 1.58–8.33).
Conclusions. It is possible to influence health care usage patterns of high-risk minority populations through public health interventions that are global in their perspective. Focusing on parental knowledge and beliefs regarding health-related issues and life skills in a self-efficacy model is associated with improved usage of infant health care resources.
Key Words: intervention program • preventive health care visits • parenting education
Abbreviations: PIP, Pride in Parenting • PSG, parent support group • DPG, developmental play group • HIB, Haemophilus influenzae vaccine • OR, odds ratio • CI, confidence interval • LBW, low birth weight • PNC, prenatal care • DPT, diphtheria, pertussis, tetanus • NIH, National Institutes of Health • NICHD, National Institute of Child Health and Human Development
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INTRODUCTION |
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The infant mortality rate in Washington, DC, in 1989 was the highest in the United States.1 At 23.2 per 1000 live births, this rate was cause for alarm among professionals and health care providers involved in the care of mothers and infants.1,2 Over the ensuing years, a reduction was observed; by 2000, the rate had dropped to 12.0 deaths per 1000 births yet still remained higher than the rate for the United States as a whole.3 In addition, the 2000 rates for blacks were 16.1 and 14.1 per 1000 for Washington, DC, and the United States, respectively; both more than double the national average (6.9).3
The most important predictors of infant mortality among blacks are low birth weight (LBW) and prematurity.4 Much of the discrepancy between infant mortality rates among blacks and whites can be explained by discrepancies in prematurity and LBW rates. In 2000, the rate of prematurity among whites (10.6%) was significantly less than that for blacks (17.4%).5 Furthermore, the LBW rates in blacks were more than twice that of whites and Hispanics (13.1% vs 6.6% and 6.4%, respectively).5 In Washington, DC, the LBW rate for blacks was even higher at 14.0%, compared with only 7.4% for whites.5 Other factors contributing to the discrepancy in infant mortality among blacks include sudden infant death syndrome, respiratory distress syndrome, infections, congenital abnormalities, and injuries.4,6
A number of prevention strategies have been suggested for reducing rates of infant mortality among blacks. Research suggests that efforts should begin before conception and continue through the postpartum period and infancy to increase access to and use of preventive health care services.6–8 Access and usage of preventive pediatric services among blacks continues to trail significantly behind national averages. Black infants are significantly less likely to receive adequate well child care during the first 6 months of life and less likely to receive age-appropriate immunizations.9,10 Poor, minority, and uninsured children also lack a consistent source of care and use fewer physician services than do white, non-poor, and insured children.11,12
A variety of programs have been tested with varying degrees of success to improve preventive health care, immunization rates, and infant screening among minority inner-city populations. Such programs included parent education and case management, food voucher incentives, home visits, facilitated access to services, and outreach.13–18
The current study focuses on improving mothers’ parenting knowledge, attitudes, and practice as a means of impacting pediatric health care usage that in turn will impact infant mortality rates.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Study Design
Among black women, prenatal care (PNC) usage is considerably lower in Washington, DC residents compared with the rest of the United States. In 2000, the percentage of pregnant blacks in Washington, DC, with late or no PNC was 9.6% compared with national estimates of 6.7% for blacks and 3.3% for all races combined.5 The Pride in Parenting (PIP) study was a randomized, controlled trial designed to test the efficacy of a community-based intervention in improving preventive health care usage among low-income, minority mothers in Washington, DC.
The study population consisted of mothers receiving no or inadequate PNC, who were randomized to intervention and control groups. Late or no PNC is often associated with maternal behaviors that contribute to suboptimal parenting and inadequate use of pediatric preventive services.19–21 It was hypothesized that an intervention focusing on parenting skills as part of a "self-efficacy" curriculum could improve maternal use of preventive infant health care, and, consequently, on infants’ survival.
Participants
Enrollment occurred during the immediate postpartum hospitalization. Delivery logs were used to identify eligible women. Eligibility was confirmed if they resided in Washington, DC, and had an inadequate or no PNC. Inadequate PNC was defined as <5 prenatal visits or care initiated in the third trimester. Mothers had to be at least 18 years old, speak English, have no history of psychiatric illness, not incarcerated or otherwise institutionalized, and not planning to place the infant for adoption. Mothers were excluded if their infants were delivered before 34 weeks of gestation, weighed below 1500 g, or had congenital abnormalities. Recruitment began in April 1995 and ended in April 1997 in 4 Washington, DC hospitals (Columbia Hospital for Women, DC General Hospital, George Washington University Hospital, and Howard University Hospital). The institutional review boards of all participating institutions approved the protocol. All participants were provided written informed consent.
A total of 13 705 mother-infant records were screened; 426 were eligible and approached for recruitment. Of these, 67.1% (286) of the women consented to participate and were enrolled. After enrollment, baseline data were collected by reviewing hospital records and conducting personal interviews with mothers before discharge. Baseline data included an assessment of maternal and infant characteristics including maternal age, race/ethnicity, marital status, socioeconomic status, reproductive and pregnancy history, use of PNC during the index pregnancy, history of drug and alcohol use, and infant health at delivery.
Randomization
Eligible mother-infant dyads were assigned either to the intervention arm or the standard social services (control) group. To ensure comparable numbers within each group across the 4 hospitals, site-specific block randomization was used. Block randomization ensured avoiding selection bias attributed to demographic differences across the 4 sites. The Data Coordinating Center randomized participants and assigned study identification numbers. After the baseline interview was completed, the Data Coordinating Center provided recruitment staff with the participants’ randomization assignment.
Follow-Up Data
Follow-up interviews on health care usage for infants were conducted with mothers at 4, 8, and 12 months post hospital discharge. Information about timing of health care visits, name of provider (to facilitate verification), and services provided during the visit was collected at 16-week intervals to minimize recall bias and was verified from providers’ medical record.
Mothers’ data regarding health care usage for infants were verified from providers’ medical records. During the 3 follow-up interviews, mothers provided written consent to release medical record information for their infants. Enrolled mothers identified 103 health care providers delivering care to their infants. Among these providers, mothers reported 926 infant visits to hospitals and clinics, of which 911 were confirmed. A total of 212 infant care visits to individual providers were reported by mothers, which increased to 222 on verification. In addition, there were 7 visits reported by mothers to providers outside of Washington, DC, but 10 were confirmed. Finally, a total of 26 infant care visits were reported by mothers, which were not verified by medical record review.
Intervention Delivery
Intervention mothers participated in a year-long, multicomponent intervention including home visits, parent-infant developmental play groups (DPGs), parent support groups (PSGs), and monthly support calls from the PIP family resource specialist. The home visits initially occurred weekly and were conducted by a lay home visitor who had participated in a 9-week training program.22 Home visitors worked to establish a supportive, cooperative relationship with mothers and to respond to the mothers’ individual needs. Home visitors followed a standardized curriculum during the visits, including instruction on various parenting health and child care topics that coincided with the age and development of the infant. They also provided health and development information and facilitated parental usage of community health and social service resources.
When the infants reached 5 months of age, home visits were interchanged with biweekly group sessions consisting of a 45-minute DPG followed by a 45-minute PSG. Group sessions were conducted at each of the hospital sites and were lead by an experienced infant development specialist. The goals of the DPG were to increase parental knowledge of infant development and to improve parent-infant interactions. The PSGs were designed to reinforce developmental concepts presented in DPGs and to address issues of daily care, preventive health care, safety, family concerns, and parenting problems. The PSGs also provided mothers with opportunities to develop social support networks and to share concerns and gain confidence in their ability to carry out personal and parental tasks and responsibilities. As with the home visits, lesson plans were developed for each DPG and PSG session to ensure consistency across sites.
The PIP curriculum included plans for 32 home visits and 16 DPG/PSG sessions. Details regarding the intervention are presented elsewhere.22,23 The median for mothers’ participation in the scheduled interventions, including both home visits and group sessions, was 30 contacts. This level of participation was chosen for classification of mothers into 2 groups: high- (30 contacts or more) and low- (<30 contacts) intensity intervention participation. Thirty sessions were considered to offer the minimum opportunity to cover a significant portion of the curriculum.
During the infants’ first year of life, mothers in the control group received standard social services support offered at the recruitment hospital. They also received monthly telephone calls from a PIP family resource specialist, who provided referrals to health care and social support services and other community resources. The PIP intervention focused on improving mothers’ parenting knowledge, attitudes, skills, and behaviors. The intervention also promoted social competence, defined as the ability to recruit and maintain a social support network at the personal, family, and community levels. The primary outcome of the study was improved usage of infant preventive health care services. We hypothesized that intervention mothers compared with control mothers would demonstrate improved usage of preventive health care for their infants.
Study Outcomes
The outcome of the study was usage of preventive health care services during the infant’s first year of life. The primary statistical issue was whether, and how much, preventive health care usage differed between intervention and control groups. The measures chosen to evaluate this outcome were well-infant care and immunization visits, as reported by mothers and verified by health care providers. It was hypothesized that intervention mothers would report more well infant care visits, more immunization visits, and would initiate these visits earlier. We also hypothesized that intervention mothers would demonstrate greater adherence to age-appropriate health supervision and immunization schedules as measured by: 1) 3 or more well infant care visits by 9 months of age; and 2) first immunizations received by 4 months, second immunizations by 6 months, and completed immunization schedule by 9 months. A completed primary immunization series was defined as 3 doses of diphtheria, pertussis, tetanus (DPT), 2 doses of oral polio, and 3 doses of Haemophilus influenzae vaccine (HIB).
Comparisons of intervention and control groups with respect to immunizations were addressed in 2 ways. First, the frequency of visits intended by mothers for immunization was compared, regardless of the number or type of immunizations received. In addition, specifics about adherence to the age-appropriate immunization schedule and types of immunizations (DPT, polio, HIB, etc) received for the 2 groups were also compared.
Statistical Methods
Statistical analysis consisted of 2 stages. In the first stage, baseline characteristics of the intervention and control groups were compared. In addition, the intervention group was subdivided into low- and high-intensity intervention groups. These 2 subgroups were similar with respect to baseline demographic variables.
In the second stage of analysis, contingency tables were generated using SAS statistical software to test bivariate associations (SAS Institute, Cary, NC).24 The intervention and control groups were compared with respect to the outcome variables, number of well-infant visits, and immunizations at 4, 6, 9, and 12 months. Because site-specific block randomization was used, there was no need for site-specific analysis. Exact nonparametric statistical inferences were applied and StatXact statistical software (CYTEL Software Corporation, Cambridge, MA), developed to handle small-sample data by exact permutational methods, was used to arrive at accurate and valid results. Since statistical significance is a function of the sample size used in the analysis, exact P values are reported so that the comparisons between intervention and control groups may be placed in the right perspective.25 However, the authors recognize that the power of some statistical tests will be adversely affected by the small sample sizes in some cells.
The impact of the intensity of the on various health care usage measures was assessed using the Cochran-Armitage trend test.26,27 The Cochran-Armitage trend tests the progressive increase in these measures with the increasing intensity of the intervention from none (control group) to those in the intervention with <30 contacts (low-intensity group) and to those with at least 30 contacts (high-intensity group). We tested the hypothesis that the intensity of the intervention did not affect health care usage for the various measures investigated against the hypothesis that usage increased from the control group to the low-intensity intervention group to the high-intensity intervention group. Thus, we tested the trend in preventive health care usage.
Multivariate techniques were used to assess the effect of the intervention on the outcome measure of completed primary immunizations. Independent variables, identified through bivariate analyses as being associated with the outcome variable or identified through prior literature as being correlates of health care usage, were used as control variables: education, firstborn child status, history of abortion, and smoking, alcohol, and illicit substance use in pregnancy. Logistic regression models were developed and adjusted odds ratios (ORs) were calculated, measuring how much more likely it was for infants in the intervention group to have completed the immunization schedule as compared with the infants in the control group.
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RESULTS |
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Comparison of Treatment Groups on Background Characteristics
For the 286 enrolled mother-infant dyads, 146 were assigned to receive the intervention and 140 were assigned to the control group. Table 1 shows the characteristics of the mothers in the 2 groups. No significant differences were found. Nearly all mothers were black (98.6%) and had never been married (90.6%). More than half had completed at least a high school education (54.9%) and were living below the poverty level (60.1%). Most mothers (93%) stated that the current pregnancy was unwanted. Approximately 28% of the mothers had smoked during pregnancy, 19.9% drank alcohol, and 12.9% used illicit substances. When the intervention group was divided into subsets according to their level of participation in the intervention, no significant differences were found between the high- and low-intensity participation groups with respect to demographic or socioeconomic characteristics.
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Of those 286 mothers recruited into the study, 207 (72.4%) were retained at 4 months, 187 (65.4%) at 8 months, and 167 (58.4%) at 12 months. The main causes of attrition were moving out of Washington, DC or placement of infants outside their mothers’ care. A comparison of characteristics of the mothers retained and those dropping out is conducted and detailed in another paper.28 The only statistically significant difference between groups was that a higher percentage of early dropouts using no PNC. For mothers retained, control and intervention groups were not significantly different with respect to demographic and socioeconomic characteristics at various points in time during the follow-up year.
Well-Infant Care Usage
Table 2 compares the timing of the initial well-infant care visit; as hypothesized, mothers in the intervention group initiated care earlier than did control mothers. A higher percentage of infants in the intervention group, as compared with the control group, had attended at least 1 well-infant outpatient visit by 2 weeks, 4 weeks, and 6 weeks of age. However, the difference between the 2 groups was only statistically significant at 6 weeks (P = .0463).
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In Table 3, a comparison of the timing of preventive health care visits between the intervention and control groups at 4, 6, 9, and 12 months shows that infants in the intervention group attended more well infant visits than did infants in the control group. At 4 months, 78.3% of the intervention infants had attended at least 1 well-infant visit versus 64.1% of control infants (P = .0167). At 6 months, 68.2% of the intervention infants had attended at least 2 visits, versus 50.6% of control infants (P = .0103). At 9 months, 65.9% of the intervention infants had attended at least 3 well-infant visits as opposed to 44.2% of control infants (P = .0037). At this time, the mean number of visits for infants in the intervention group was 3.14, whereas for infants in the control group the mean was 2.18, a difference that was highly statistically significant (P = .0007). This confirmed the hypothesized study outcome that intervention mothers would demonstrate greater adherence to the age-appropriate health supervision schedule for their infants. Finally, at 12 months, 52.7% of participating intervention infants had attended at least 4 visits as opposed to 41.6% of the controls. Although this difference was not statistically significant (P = .0981), a significantly higher percentage of infants in the intervention group had attended at least 3 well-infant visits at this time (71.4% vs 51.9%, P = .0073), a number adequate to deliver the prescribed immunizations.
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Immunization Visits and Adherence to Age-Appropriate Immunization Schedules
Infants in the intervention group consistently attended more immunization visits than did infants in the control group. At 4 months, the mean number of immunization visits for the intervention group was 1.01, whereas for the control group the mean was .77 (P = .0498). At 6 months, the mean was 1.50 immunization visits for the intervention group and 1.13 for the control (P = .0295), and at 9 months the mean was 2.20 immunization visits for the intervention infants and 1.64 for the infants in the control group (P = .0125). Finally, at 12 months, the mean number of immunization visits was 2.44 for the intervention group and 2.00 for the control group (P = .0867).
The actual number of visits for infants in the intervention or control group during their first year of life shows, as hypothesized, a significantly higher percentage of intervention mothers had initiated first immunization visit by 4 months (66.7% vs 54.3%, P = .0463). For infants participating at 6 months, a significantly higher proportion of intervention infants had attended at least 3 immunization visits (P = .0100), but the percentages attending at least 1 and 2 visits did not differ significantly between groups. At 9 months, a significantly higher proportion of intervention infants had attended at least 1 immunization visit (P = .0296) and at least 2 visits (P = .0462), but there was no significant difference between the percentages of intervention and control groups who had attended at least 3 visits. At 12 months, differences between the groups in terms of completed immunization visits were not significant.
Infants in the intervention group demonstrated greater adherence to age-appropriate immunization schedules. As shown in Table 4, a significantly higher percentage of participating intervention infants had received at least 1 polio, 1 DPT, and 1 HIB immunization by 4 months (65.0% vs 48.9%, P = .0135). At 6 months, a significantly higher proportion of infants in the intervention group had received at least 2 polio shots (49.5% vs 34.9%, P = .0307) and at least 2 DPT shots (48.6% vs 33.7%, P = .0277). However, while more intervention infants had received at least 2 each of polio, DPT, and HIB immunizations, this difference was not statistically significant (41.1% vs 28.9%, P = .0556).
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As hypothesized, by 9 months, a greater proportion of infants in the intervention group, as compared with the control group, had a completed primary immunization schedule (37.4% vs 20.8%, P = .0143). In addition, significantly higher percentages of intervention infants had completed each immunization component at this time. At 9 months, the unadjusted OR for completing the primary immunization schedule was 2.3 (95% confidence interval [CI] = 1.1–4.6) for the intervention infants as compared with the control infants. Controlling for education, wantedness of pregnancy, firstborn child status, and smoking, alcohol, and illicit drug use during pregnancy, the adjusted OR for completing the immunization schedule by 9 months was very similar (OR = 2.2; 95% CI: 1.1–4.5) to the unadjusted ratio. None of the controlling variables were significant.
Although the intervention infants initiated immunizations at an earlier age and demonstrated greater adherence to age-appropriate immunization schedules, many of the control infants did eventually complete their immunization schedules. As the infants aged to 12 months, the difference between groups lost significance.
Intervention Intensity
Greater differences in health care usage patterns emerged when the intervention infants were divided into low-intensity and high-intensity subsets and compared with the control group. As shown in Table 5, infants with low-intensity intervention show a trend to more preventive health visits than control infants at both 9 and 12 months, but this difference was not statistically significant. However, at 9 months, a significantly higher percentage of infants in the high-intensity intervention group had attended at least 3 well-infant visits as compared with infants in the control group (P < .001). At 12 months, a higher percentage of infants in the high-intensity intervention group had attended at least 4 visits (P < .05), and they had .8 more visits per infant (P < .05). Furthermore, the Cochran-Armitage trend test confirmed the hypothesis that the percentage of infants attending at least 1, 2, 3, and 4 visits increased as the intensity of the intervention increases from none (control group) to the low-intensity intervention group to the high-intensity intervention group at both 9 and 12 months (see Table 5 for P values).
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A similar pattern was seen for immunization visits. Although a higher percentage of low-intensity intervention infants consistently attended more immunization visits than the control infants, the difference between the groups was not statistically significant. However, a significantly higher proportion of infants of mothers in the high-intensity intervention group had at least 1, 2, and 3 immunization visits at 9 months as compared with control infants. Interestingly, at 12 months, the proportions were not significantly different for >2 visits. The results of the Cochran-Armitage trend test indicate that the proportion of infants attending at least 1, 2, and 3 immunization visits at 9 months increased from the control to the low-intensity group to the high-intensity intervention group (see Table 5for P values). At 12 months, this trend was significant only for at least 1 and 2 visits (P = .0029 and .0317, respectively).
Modeling the completion of the primary immunization schedule at 9 months was modified slightly to reflect the effects of the intensity of the intervention in predicting this outcome. Infants in the subgroup of high-intensity intervention were 3.4 times more likely to have completed their primary immunization schedule by 9 months, as compared with control infants (95% CI: 1.5–7.4). Controlling for education, wantedness of pregnancy, firstborn child status, and smoking, alcohol, and illicit drug use during pregnancy, the adjusted OR for completing the immunization schedule by 9 months was 1.3 (95% CI: 0.5–3.1) and 3.6 (95% CI: 1.6–8.3) for the low- and high-intensity intervention groups, respectively, as compared with the control group. Mothers who received the more intensive intervention were more likely to have followed age-appropriate immunization schedules for their infants. None of the controlling variables were significant. By 12 months, although the infants of control mothers had not caught up to infants of mothers in the high-intensity intervention group, the difference between the 2 groups had lost statistical significance.
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DISCUSSION |
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Improving health care usage by populations not known to prioritize preventive health care use is a difficult equation. Resolving issues of access and coverage responds to 1 component of this equation. Personalized interventions designed to assess individual clients’ needs and respond to them appropriately are uniquely beneficial as well. In this study, we chose to address the needs of a population representing the highest end of the risk spectrum, namely minority mothers with no or poor PNC usage. We were aware a priori of the practical difficulties we could encounter in recruiting and maintaining the initiative of these mothers to participate in the study. More importantly, we were open to learning about how these mothers would respond to our intervention as well as how the health care system would respond to these mother/infant dyads and their preventive health care needs.
It is worthy of note that the effect of the intervention was most prominent in its ability to expedite the interface between the infants and the health care delivery system. First, in expediting the initial encounter, and then in expediting the follow-up preventive visits and immunization visits. The effect became less significant as more of the usual care group were able to reach the health care system, gradually overcoming obstacles, either practical or in their beliefs system. This should not detract from the value of this intervention since early and timely availability of preventive care in the first months of life is essential to the health of the infant, and delayed care may contribute significantly to morbidity and mortality.7,29
Another important finding is the clear association between the intervention intensity and the desired outcome. This relationship could either be explained by subtle differences in the subpopulations not captured in our analysis, but also may hint to a critical transition point where such a global intervention effectively impacts on health choices and behaviors.
A remarkable finding in this study is the gap between the number of visits initiated by the mothers and documented by the health care system as preventive care, and the equivalent number of doses of immunizations received. Our results show that 47.7% of infants in the intervention group had received at least 3 preventive care visits by 6 months, but only 23.4% had received at least 3 immunizations. This discrepancy is still evident at 9 months, when 65.9% had received at least 3 preventive care visits, only 44% had received at least 3 immunizations. The same applies for 12 months of age where the percentages are 71.4% and 48.3%, respectively. Part of these differences could be explained by the timing of the visits, but there is little doubt that missed opportunities play a major role. The health care system may need to exercise a different level of flexibility in administering immunizations to infants whose mothers are deemed to be at heightened social risk. Such mothers bringing their infants to clinic for a preventive health visit must be considered a golden opportunity for the delivery of all components of health promotion and disease prevention to the infant.
The operational cost of this intervention program is estimated at $5458 per infant/mother dyad. This cost was comparable to that projected for the Olds’ study when updated to the 1997 economy ($6700).30 Health care usage enhancement programs such as the 1 designed for this study are likely to have a more sustained effect than others relying predominantly on material incentives, or simply targeting the health care delivery system.14,15,31,32 Improved PNC levels, even among mothers using illicit drugs during pregnancy, have resulted in reductions in prematurity and LBW.33 Alternative strategies optimizing preventive health care during infancy suggest that group well childcare may be more cost-effective but do not necessarily impact on maternal knowledge, beliefs, or skills and mainly target infants of working mothers.31,32
A recent study from Rochester suggests a combination of strategies including tracking and outreach to families as well as prompting of the primary health care system.17 The interventions at the family level focused on reminder cards or calls and home visits to nonresponders. This combined strategy proved successful at increasing primary care visits and more up-to-date immunizations. We suggest that interventions such as the 1 administered in this study need to be examined for effectiveness not only as stand-alone programs, but also as component of multidimensional strategies targeting high-risk communities.
Valid comparisons of the cost of this study, or its efficacy, to other studies are difficult because of differences in approaches, methodologies, and contents of the intervention programs. Moreover, characteristics of populations covered by various studies in terms of demographic distribution, age group, as well as the specific risk profiling required for eligible participation are different, and warrant some sort of standardization to conduct a valid comparison of costs, and evaluation of long-term sustained effects.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study shows that an outreach intervention focusing on maternal knowledge and beliefs of health-related issues, as well as parenting, and life skills, is associated with a more timely usage of available health care resources. Improved coping and organizational skills, as well as a heightened perception of the benefits of care, may have enhanced the ability of these mothers to prioritize preventive health care and actively seek it for their infants.
In our experience, mothers with limited resources welcomed this outreach program and responded to it favorably. Yet programs such as this one are labor intensive and are met with difficulties reflecting the "life reality" for clients involved. One such challenge that we encountered was the unpredictable and frequent mobility of this population, a factor that directly influenced their participation. The main limitation in the interpretation of our results relates to the attrition rates experienced in this study. Over 25% of mothers lost to follow-up were attributable to moving out of Washington, DC or placement of infants outside the care of their mothers. Both of these factors were out of the control of the investigators.
The intervention program was successful in shifting the timing of well care and immunization visits to an earlier age. This shift has significant public health implications because it may allow for earlier recognition of clinically significant problems including delays in infants’ growth and development. Furthermore, the timely completion of immunizations (within the recommended schedule) ensures full protection of these infants against infectious risks during this particularly vulnerable period of their growth.12 In addition, recent data suggest an association between improved well care and decreased hospitalization rates in underserved populations.8
We would like to affirm the importance of reaching out to the highest risk group within our population with public health interventions that are global in their perspective and promise to have residual and sustained effects on the targeted population. The real challenge to such interventions remains their cost. It is plausible that reduction in costs may be achieved if interventions such as these are not prescribed in their entirety to the targeted population but are administered in a titrated fashion according to a continuous evaluation of the risks expressed by the individual family over time.
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ACKNOWLEDGMENTS |
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The study was supported by grants (U18-HD30447, U18-HD30458, U18-HD30450, U18-HD30445, U18-HD31919, U18-HD30454, and U18-HD31206) from the NICHD and the NIH Office of Research on Minority Health. The study was approved by the institutional review boards at all participating institutions. Signed informed consent was obtained from all participants.
This study was part of the National Institutes of Health (NIH) Washington, DC Initiative to Reduce Infant Mortality in Minority Populations in the District of Columbia (Phase I) and was funded by the NIH Office of Research on Minority Health and the National Institute of Child Health and Human Development (NICHD). The following institutions and investigators participated in the NIH Washington, DC Initiative to Reduce Infant Mortality in Minority Populations in the District of Columbia: the Children’s National Medical Center, P. Scheidt (Principal Investigator); the Washington, DC Department of Public Health, B. J. Hatcher (Principal Investigator); Washington, DC General Hospital, L. Johnson (Principal Investigator); Georgetown University Medical Center, K. N. Sivasubramanian (Principal Investigator); Howard University, B. D. Wesley (Principal Investigator); University of the District of Columbia, V. Melnick (Principal Investigator); Research Triangle Institute, A. V. Rao (Principal Investigator); and NICHD, H. W. Berendes (Program Officer), A. A. Herman (Scientific Coordinator), and B. K. Wingrove (Program Coordinator).
The authors appreciate very much the comments and suggestions received on an earlier draft from Michele Kiely, the program officer at the NICHD.
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FOOTNOTES |
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Received for publication Jul 10, 2002; Accepted Nov 18, 2002.
Reprint requests to (A.A.E.E.) Professor of Prevention, Community Health and Pediatrics/Obstetrics and Gynecology, George Washington University Medical Center, Ross Hall, Suite 125, 2300 I St, NW, Washington DC 20037. E-mail: sphaxe{at}gwumc.edu
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