TAX-SUPPORTED MEDICAL CARE FOR CALIFORNIA'S CHILDREN—Where Should It Be Going?

The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support.     

Withholding or Withdrawing Extraordinary Life Support—Optimizing Rights and Limiting Liability

For many years physicians, ethicists and members of the legal community have attempted to minimize ambiguity and unpredictability in making decisions to withhold or withdraw extraordinary life support. Recent developments in national and California law now afford medical care providers unparalleled protection from criminal and civil liability in surrogate decision-making situations. They also reinforce the concept of patient''s rights by providing medical care consumers with new and effective mechanisms for enforcing their “right to decide,” even after they have lost decision-making capacity. A case in point is California''s new Durable Power of Attorney for Health Care, which serves as a model for other jurisdictions that do not have such legislation. Thus, the medical and legal professions, working together, can contribute immeasurably to respectful medical decision making by educating the public about these developments and by adopting policies that reinforce these rights.     

Parental attitudes toward pediatric organ donation: a survey.

We conducted a telephone survey of parents in the National Capital Region to assess their intention to donate their child''s organs and to provide physicians with information that could help alleviate their concerns about approaching parents for consent. Of 339 parents who agreed to answer questions after being given details of their child''s "death" 288 (85%) said that they would be willing to donate their child''s organs. The degree of willingness was associated with the certainty of death, altruism and empathy toward children in need of an organ, previous discussion of organ donation with a family member and knowledge of an adolescent or adult child''s attitude toward donation. Factors that inhibited the intention to donate included uncertainty of death, insufficient information from medical professionals and fear of multilation. The child''s age was not significantly associated with intention to donate. Concordance between the results and actual donation rates in Canada and the United States supports the generalizability of the survey findings.     

Prevention of psychosocial problems in children with chronic illness.

Children with chronic illness and disability are at considerably increased risk of psychosocial problems, such as neurosis, attention deficit and poor adjustment to school. Health care professionals, especially primary care physicians, can do a great deal to prevent such problems in these children and their families. The approach outlined here is based on an understanding of the transactional model of development, in which the child interacts with--and to some extent creates--the social environment, and on a "noncategorical" concept in which common elements in chronic illness are recognized and emphasized. The physician''s role is to inform the family of the child''s condition as soon as possible, to offer hope, encouragement and guidance, to watch the child''s development, to maintain a shared view of the child and family, and, if possible, to ensure continuity of care.     

Agricultural medicine: fighting health hazards down on the farm.

The delegation of a medical act to persons other than physicians may be appropriate in certain restricted circumstances in the interests of good patient care and efficient use of health care resources. The CMA''s Guidelines for the Delegation of a Medical Act were established to help physicians when they decide to delegate a medical act to a person other than a physician. Such delegation does not absolve the physician of responsibility for the care of the patient; it merely widens the circle of responsibility for the safe execution of the procedure.     

Socio-Cultural Determinants of Health-Seeking Behaviour on the Kenyan Coast: A Qualitative Study

Background

Severe childhood illnesses present a major public health challenge for Africa, which is aggravated by a suboptimal response to the child''s health problems with reference to the health-seeking behaviour of the parents or guardians. We examined the health-seeking behaviour of parents at the Kenyan coast because understanding impediments to optimal health-seeking behaviour could greatly contribute to reducing the impact of severe illness on children''s growth and development.

Methods and Results

Health-seeking behaviour, and the factors influencing this behaviour, were examined in two traditional communities. We held in-depth interviews with 53 mothers, fathers and caregivers from two rural clinics at the Kenyan Coast. Biomedical medicine (from health facilities and purchased over the counter) was found to be the most popular first point of treatment. However, traditional healing still plays a salient role in the health care within these two communities. Traditional healers were consulted for various reasons: a) attribution of causation of ill-health to supernatural sources, b) chronic illness (inability of modern medicine to cure the problem) and c) as prevention against possible ill-health. In developing an explanatory model of decision-making, we observed that this was a complex process involving consultation at various levels, with elders, but also between both parents, depending on the perceived nature and chronicity of the illness. However, it was reported that fathers were the ultimate decision makers in relation to decisions concerning where the child would be taken for treatment.

Conclusions

Health systems need to see traditional healing as a complementary system in order to ensure adequate access to health care. Importantly, fathers also need to be addressed in intervention and education programs.     

Psychological effects of false-positive results in expanded newborn screening in China

Objectives

As more families participate expanded newborn screening for metabolic disorders in China, the overall number of false positives increases. Our goal was to assess the potential impact on parental stress, perceptions of the child''s health, and family relationships.

Methods

Parents of 49 infants with false-positive screening results for metabolic disorders in the expanded newborn screening panel were compared with parents of 42 children with normal screening results. Parents first completed structured interview using likert scales, closed and open questions. Parents also completed the parenting stress index.

Results

A total of 88 mothers and 41 fathers were interviewed. More mothers in the false-positive group reported that their children required extra parental care (21%), compared with 5% of mothers in the normal-screened group (P<0.001). 39% of mothers in the false-positive group reported that they worry about their child''s future development, compared with 10% of mothers in the normal-screened group (P<0.001). Fathers in the false-positive group did not differ from fathers in the normal-screened group in reporting worry about their child''s extra care requirements, and their child''s future development. Children with false-positive results compared with children with normal results were triple as likely to experience hospitalization (27%vs 9%, respectively; P<0.001).

Conclusions

The results showing false-positive screening results may affect parental stress and the parent-child relationship. Parental stress and anxiety can be reduced with improved education and communication to parents about false-positive results.     

Health Data and the Physician

California Health Data Corporation was formed to create better health data resources under the direction of hospitals and medicine. Highest priority is being given to developing information systems that will serve physicians, as well as those who are usually considered health data users. This is illustrated in CHD''s first major activity, sponsorship of a medical record information system for California hospitals. This system is designed first of all to provide better information for medical staff committees, and as a byproduct to provide data flow into a CHD data bank. For the practicing physician, the significance of CHD is that the organization will attempt to develop information systems that will help the medical profession maintain its central role in guiding the present and future patterns of health care.     

Maternal trade-off in treating high-risk children

Low birthweight and the infant's health status are expected to strongly influence the child's reproductive value and, thus, the maternal decisions on the amount and timing of investment. A total of 590 Hungarian primiparous mothers giving birth in the late 1980s were recruited for the longitudinal study. Mothers of high-risk infants shortened the duration of breast-feeding and interbirth intervals, compared to those with an infant of higher survival prospects. The most powerful predictor of the length of the lactation period was the infant's weight at birth, whereas birth spacing was significantly influenced by the health status of the older child. Socioeconomic status had a positive effect on maternal care as well, but it did not change the basic pattern of diminishing maternal care as a function of the infants' low reproductive value. The combination of the above factors resulted in a cumulative effect on maternal investment of mothers with handicapped children of various degrees of risk. An attempt has been made to exclude alternative explanations and to discuss the proximate mechanisms of discriminative parental solicitude.     

Consumer demand for caesarean sections in Brazil: informed decision making,patient choice,or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods

ObjectivesTo investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment.DesignPopulation based birth cohort study, using ethnographic and epidemiological methods.SettingEpidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed.Participants5304 women who gave birth in any of the city''s hospitals in 1993.ResultsIn both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women''s behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education.ConclusionsFear of substandard care is behind many poor women''s preferences for a caesarean section. Variables pertaining to women''s role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed.

What is already known on this topic

Women''s preferences for caesarean sections are understood to result from lack of knowledge and psychological aptitude to handle vaginal delivery and its consequencesEfforts to reduce the demand for caesarean sections have focused on providing consumers with correct information on the relative risks associated with vaginal and operative deliveries

What this study adds

In Brazil, many women prefer caesarean sections because they consider it good quality careRich women are more likely to have caesarean sections, supporting the notion that medical intervention represents superior carePoor women may implement a series of medicalised practices that justifies the need for greater medical intervention during birthInterventions for reducing caesarean sections by educating physicians and patients about risk factors associated with birthing procedures are not sufficient     

Another Look at the Medical “Generation Gap”—Second Triennial Survey of Attitudes of Medical Students and Recent Graduates

A 1969 survey of attitudes held by medical students and recent graduates was repeated in 1972, using the same samples of respondents and adding a new freshman group. Findings from both surveys showed that a “generation gap” existed on many issues.Furthermore, a comparison of the two studies suggested that two kinds of attitude change are occurring simultaneously. On some issues, the next generation of physicians will probably continue to differ from their predecessors. Perhaps the primary thread woven through this cluster of attitudes is that today''s medical students and young physicians perceive themselves as members of a larger structure for providing health care.However, many of the students'' attitudes held early in their medical careers appear to have been modified in the process of becoming physicians. It appears that medical education continues to convey many traditional professional values to students, and it seems likely that tomorrow''s physicians will retain a core of those values.     

REPORT FROM OTTAWA

In a national disaster, the medical profession would lose physicians and auxiliary personnel and would need assistance. Canada''s 22,000 physicians and 85,000 nurses are located for the most part in potential target areas. Survivors among Canada''s 6396 dentists could supply 30% reinforcement. The dentist''s training, his manual dexterity and experience acquired in the management of hemorrhage, shock, débridement, suturing, reduction and immobilization of fractures, and control of pain and infection would be valuable. Additional functions he could perform would be first-aid, including but not limited to artificial respiration, early management of chest wounds, preparation of casualties for movement, and assistance in general surgical procedures. Dentists with special training in anesthesia, oral surgery or public health could be of particular value in relieving anesthetists, surgeons, radiologists and public health officers of some of their duties. Joint training of physicians and dentists in mass casualty care could increase the efficiency of the team work in disaster and is being considered by many medical and dental faculties.     

Childhood Obesity: Do Parents Recognize This Health Risk?

Objective: This study examined parents’ understanding of excess weight as a health risk, knowledge of healthy eating habits, and recognition of obesity in their children. Research Methods and Procedures: An anonymous questionnaire was distributed during well‐care visits involving children 4 to 8 years of age at a pediatric faculty practice. Parents indicated their level of concern about excess weight and other familiar health risks using a four‐point Likert scale, answered multiple‐choice questions concerning healthy eating patterns, and communicated their perceptions about their child's weight using a visual analog scale. A parent's perception was considered “accurate” if it deviated from the child's growth chart percentile by <30 points. Results: Of the 83 parents surveyed, 23% (19/83) had overweight children (≥95th percentile of age‐ and gender‐specific BMI growth charts). These parents did not differ from other parents in their level of concern about excess weight as a health risk or in their knowledge of healthy eating patterns, but the two groups of parents did differ in the accuracy of their perceptions about their children's weight. Only 10.5% of parents of overweight children (2/19) perceived their child's weight accurately compared with 59.4% of other parents (38/64; p < 0.001). Parents of overweight children invariably underestimated their children's weight. The median difference between their perception and the growth chart percentile was ?45 points. Discussion: Given that most parents of overweight children fail to recognize that their child has a weight problem, pediatricians should develop strategies to help these parents correct their misperceptions.     

Mental Health of Parents as Caregivers of Children with Disabilities: Based on Japanese Nationwide Survey

The number of children with disability is increasing gradually in Japan. Previous researches in other countries have reported that parents as caregivers (CGs) of children with disability have mental health problems, but the actual situation has not been examined nationwide in Japan so far. The aim of this study was to evaluate the association between mental health of CGs who had children with disability and characteristics of children, CGs, and household based on the nation-wide survey. This study utilized data from 2010 Comprehensive Survey of the Living Conditions, and defined children with disability aged 6 to 17. Individual data of children and CGs were linked, and 549 pairs of them were extracted. The Japanese version of Kessler 6 (K6) was used to assess mental health status of caregiver, scored 5 and over represented to general psychological distress. Logistic regression was used to evaluate the associations of interest. The almost half (44.4%) of CGs had psychological distress (k6 score; 5 +) in nationwide, and 8.9% of CGs might have serious mental illness (K6 score; 13+). After adjusting covariates of child, CG, and household factors, CG having a current symptom (OR, 95% CI: 3.26, 1.97–5.39), CG''s activity restriction (OR, 95% CI: 2.95, 1.38–6.32), low social support (OR, 95%CI: 9.31, 1.85–46.8), three generation family (OR, 95% CI: 0.49, 0.26–0.92), and lower 25% tile group of monthly household expenditure (OR, 95% CI:1.92, 1.05–3.54), were significantly associated with psychological distress of CGs. This study encourages health care providers to pay more attentions toward parent''s mental health, especially for in case of having low social support, and lower income family. Further research should examine the detailed information of child''s disease and disability, medical service use, and quality and quantity of social support in nationwide to straighten the system for supporting services of both children with disabilities and their CGs.     

Chinese Medical Association anxious to establish ties with CMA

Included in China''s health care reforms are plans to forge ties with businesses and physicians in Canada. The current challenges centre around the standardization of medical education in China, issues that a Chinese delegation raised during a recent visit to Canada.     

Where is the silver lining? Anxious doctors ask.

When Nova Scotia elected a Liberal government in September 1993, a wave of optimism washed over the province''s medical community. One of their own, Dr. John Savage, was now premier, and another, Dr. Ron Stewart, was minister of health. However, anticipation soon turned to anger as Stewart took aim at physician fees and hospital costs to help reduce the province''s health care budget by $62 million. Last November, relations between him and the Medical Society of Nova Scotia (MSNS) hit bottom. In an uncharacteristically political move, the society launched an ad campaign featuring slogans such as "Death by 1000 cuts" and "Uncle Sam want me. Ron Stewart doesn''t." Four months later, the health department and the MSNS called a truce, with an agreement that many physicians consider a positive step. Today the province and its doctors are speaking again, and the medical society is working hard to help define physicians'' roles in a new, regionalized health care system. But has the mood of doctors really improved? Last spring, CMAJ interviewed a cross section of Nova Scotia physicians to find out.     

Evaluation of a Comprehensive Care Clinic Model for Children With Brain Tumor and Risk for Hypothalamic Obesity

The objectives of this study were to evaluate outcomes of a comprehensive care clinic (CCC) for children with hypothalamic obesity due to treatment for brain tumors by assessing weight parameters; health‐related quality of life (HRQoL); and perception of health status, disease burden, care satisfaction, and physical activity. Thirty‐nine patients (16 males) were reviewed. While attending the CCC the median %weight gain and percent ideal body weight (%IBW) of patients was lower (8.5%/year (range ?3 to ?14) and ?4%/year (141.7–34), respectively) than the median %weight gain and %IBW (21.4% (15.8?32.0) and 19.9% (?18.7 to 149.2)) while treated in standard care. Rate of increase in %BMI slowed (4.5 kg/m² %/year (?17.8 to 8.4) vs. 8.4 kg/m² %/year (?3.1 to 28.1)) in patients attending the clinic compared to their before treatment in standard care. There was no change in blood pressure, fasting glucose, triglycerides or low‐density lipoprotein cholesterol, and a significant increase in high‐density lipoprotein cholesterol (1.09 ± 0.33 to 1.24 ± 0.04). After attending the CCC for a year, significant increases for child reported total HRQoL (63.7 ± 18.4–71.3 ± 13.3; P < 0.017), physical functioning (65.3 ± 15.9–69.5 ± 15.9; P < 0.045) and school functioning (61.1 ± 21.0–71.1 ± 16.5; P < 0.051) were found. Parents reported no significant change in HRQoL over the same period. Parents had significantly improved responses in areas of coordination of health care and understanding of their child's disease. Patients attending the CCC gained less weight while attending the clinic and exhibited improved HRQoL. Parents noticed improvements in various areas of their child's medical care.     

Can children withhold consent to treatment?

A dilemma exists when a doctor is faced with a child or young person who refuses medically indicated treatment. The Gillick case has been interpreted by many to mean that a child of sufficient age and intelligence could validly consent or refuse consent to treatment. Recent decisions of the Court of Appeal on a child''s refusal of medical treatment have clouded the issue and undermined the spirit of the Gillick decision and the Children Act 1989. It is now the case that a child patient whose competence is in doubt will be found rational if he or she accepts the proposal to treat but may be found incompetent if he or she disagrees. Practitioners are alerted to the anomalies now exhibited by the law on the issue of children''s consent and refusal. The impact of the decisions from the perspectives of medicine, ethics, and the law are examined. Practitioners should review each case of child care carefully and in cases of doubt seek legal advice.     

Effects of childhood cancer on long-term survivors and their families.

Problems experienced by families of long-term survivors of acute lymphatic leukaemia and Wilms''s tumour were investigated to find out the best way of using limited resources to improve management of such patients. All patients had received treatment at Alder Hey Children''s Hospital, and all had completed treatment at least two years before the study. A social worker interviewed the parents of each child. The results showed that various aspects of management needed improvement, including: information given to parents at diagnosis of their child''s illness and during subsequent treatment; continuity of care and multidisciplinary teamwork among those caring for the child; greater understanding by school teachers that such children have the same educational needs as others; wider communication by hospital staff with the child''s other relatives, particularly grandparents; financial help for parents; and marital counselling. To help implement these proposals full-time social workers were attached to the hospital. Preliminary results were encouraging, though it is too early to evaluate the long-term effects of the changes.     

Cultural Identity and Internationally Adopted Children: Qualitative Approach to Parental Representations

Approximately 30 000 children are adopted across national borders each year. A review of the literature on the cultural belonging of these internationally adopted children shows substantial differences between the literature from English-speaking countries and that from France and Europe in general. The objective of this study is to start from the discourse of French adoptive parents to explore their representations of their child''s cultural belonging and their positions (their thoughts and representations) concerning connections with the child''s country of birth and its culture. The study includes 51 French parents who adopted one or more children internationally. Each parent participated in a semi-structured interview, focused on the adoption procedure and their current associations with the child''s birth country. The interviews were analyzed according to a qualitative phenomenological method, Interpretative Phenomenological Analysis. The principal themes that emerged from our analysis of the interviews made it possible to classify the parents into three different groups. The first group maintained no association with the child''s country of birth and refused any multiplicity of cultural identities. The second group actively maintained regular associations with the child''s country of birth and culture and affirmed that their family was multicultural. Finally, the third group adapted their associations with the child''s birth country and its culture according to the child''s questions and interests. Exploring parental representations of the adopted child enables professionals involved in adoption to provide better support to these families and to do preventive work at the level of family interactions.