National Center for Education in Maternal and Child Health

MCH Alert Home Page

July 14, 2000

1. Study Compares SCHIP-Eligible Children With Other Insured Children

2. Study Finds States at Early Stage in Implementing Quality-Oversight Systems for Medicaid-Insured Children

3. Article Identifies Factors Affecting Breastfeeding Rates for WIC Participants

4. Reports Discuss Risks of Adolescent Employment and Farmworking

5. GAO Report Finds That NIH Studies Include Women in Research but Do Not Analyze by Sex

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Readers: The Federal Interagency Forum on Child and Family Statistics has released its fourth annual report, America's Children: Key National Indicators of Well-Being. The report is available at <http://www.childstats.gov>.
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1. STUDY COMPARES SCHIP-ELIGIBLE CHILDREN WITH OTHER INSURED CHILDREN

Children eligible for the State Children's Health Insurance Program (SCHIP) differ substantially from Medicaid-enrolled children, and policymakers need to take the differences into account when setting policies and implementing programs to increase health insurance coverage and access to health care, concludes a study in Pediatrics. The author compared the sociodemographic and health status characteristics of the SCHIP-eligible population with those of Medicaid-enrolled children, privately insured children, and privately insured children whose family income is in the SCHIP eligibility range. She used data for 50,950 children ages newborn to 18 included in the 1993 and 1994 National Health Interview Surveys. Children under age 19 living in households with income levels under 200% of the federal poverty level were defined as being SCHIP eligible.

The study's findings include the following:

• SCHIP-eligible children live with college-educated (39.4%) and employed adults (91.2%) more often than do Medicaid-enrolled children (23% and 53.9%, respectively).
• SCHIP-eligible children live with college-educated and employed adults less than all privately insured children (66.7% and 96.9%, respectively) and less than privately insured children whose families have the same income (57.8% and 97%, respectively).
• Parents of SCHIP-eligible children are disproportionately self-employed or employed in industries (e.g., retail trade) in which health insurance coverage is less available or affordable.
• SCHIP-eligible children are twice as likely as Medicaid children to be adolescents and one-and-a-half times more likely to be in excellent health.
• Compared to privately insured children, SCHIP-eligible children are nearly three times more likely to be Hispanic and nearly twice as likely to be rated in fair or poor health. However, a larger proportion of privately insured children have chronic conditions.

The author mentions that a limitation of the National Health Interview Survey data is that it only measures insurance status at the time of the survey instead of measuring possible fluctuations over the course of a year. Nonetheless, she states that her findings have policy implications, including that "the SCHIP population consists of disproportionately more adolescents than does the Medicaid group and will require a different mix of health care services (e.g., substance abuse and sexually transmitted disease prevention and treatment rather than immunizations and treatment for otitis media) to be available from appropriately trained providers." The article further notes the significance of the finding that Hispanics account for a much greater proportion of the SCHIP-eligible population than of the privately insured population. This means that materials written in Spanish are needed, and that bilingual health care providers and administrative personnel should be hired and trained.

Byck GR. 2000. A comparison of the socioeconomic and health status characteristics of uninsured, State Children's Health Insurance Program-eligible children in the United States with those of other groups of insured children: Implications for policy. Pediatrics 106(1):14-21.

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2. STUDY FINDS STATES AT EARLY STAGE IN IMPLEMENTING QUALITY-OVERSIGHT SYSTEMS FOR MEDICAID-INSURED CHILDREN

A study examining state quality-oversight mechanisms for Medicaid-insured children finds that the state Medicaid agencies surveyed focused primarily on preventive care services. The study, which was published in the Archives of Pediatrics & Adolescent Medicine, finds that states are still in the initial phases of designing and implementing quality-oversight systems for Medicaid-insured children. In 1998 the authors interviewed state Medicaid officials in 39 states, seeking to identify Medicaid managed care (MMC) requirements for using Health Plan Employer Data and Information Set (HEDIS) and other performance measures for children ages newborn to 21. The Medicaid agencies required managed care organizations to report on immunization rates; well-child visit rates; and Early and Periodic Screening, Diagnostic and Treatment (EPSDT) rates but placed relatively little emphasis on acute care measures. The authors note that children represent the largest group enrolled in MMC.

The authors questioned the state Medicaid officials about their use of performance measures in three areas: effectiveness of care, use of services, and access and availability of care. Their findings include the following:

• The most commonly used measure of effectiveness of care for children was the administration of childhood immunizations.
• The early detection and screening measure most often required by states was the low-birthweight rate.
• Reporting of pediatric acute-illness treatment measures was seldom part of state requirements. Only 7 of the 39 states had an acute illness measure for children.
• State Medicaid agencies required reporting of chronic-illness treatment measures more often than reporting of acute treatment measures.
• States were less likely to monitor treatment of mental health conditions than treatment of chronic physical conditions. States using managed care plans to deliver both physical and mental health services were twice as likely to have quality reporting requirements concerning mental health than states that contracted separately with behavioral health plans.
• Concerning use of services, the service for children that was most often monitored was inpatient hospital care (31 states). Ambulatory care use rates were monitored in 29 states.
• Compared with measures for effectiveness of care and service use, few measures for access and availability specifically for children were identified.
• The pediatric access performance measure most often used by state Medicaid agencies was access to primary care providers (26 states).
• Two-thirds of the 28 states that capitated dental services had an access measure for dental care.

Stressing that states are still in the early stages of performance measurement, the authors note that "these findings suggest the need for the federal government to establish a minimum uniform set of pediatric quality reporting requirements that addresses not only preventive care but also acute and chronic care for children." They also note that states sought more technical support (e.g., improved data systems) to implement current HEDIS requirements, and that they also sought guidance on the use of encounter data.

McManus MA, et al. 2000. How far have state Medicaid agencies advanced in performance measurement for children? Archives of Pediatrics & Adolescent Medicine 154(7):665-671.

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3. ARTICLE IDENTIFIES FACTORS AFFECTING BREASTFEEDING RATES FOR WIC PARTICIPANTS

An article published in the American Journal of Health Behavior studied 189 first-time mothers participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Arizona to determine what factors influenced their breastfeeding behavior within 6 months after giving birth. The authors found that family or friends had the largest impact on the incidence of breastfeeding, with the incidence increasing by 81% if the mother received breastfeeding information from either family or friends. Family and friends also influenced duration of breastfeeding.

The study also found that offering incentive items to the WIC population affected breastfeeding rates. Incentives items like breast pumps, breast cream, and breast pads resulted in a higher likelihood of breastfeeding, suggesting that "low-cost gifts, or incentives to [breastfeed] should be included in interventions designed for women with limited incomes." Women who received incentives breastfed for 77.5% longer than those who did not receive incentives. Furthermore, women receiving formula gift packs in this study breastfed their babies for 25% less time than women who did not receive formula gift packs or did not remember receiving them.

The mother's education was positively associated with breastfeeding (i.e., women with more formal education were more likely to initiate and continue breastfeeding than those with less formal education). Also, mothers who received direct help (telephone information, home visit, etc.) from the WIC staff after they had given birth breastfed for approximately 34% longer than those who did not receive such help, suggesting that postpartum interventions are an important part of an effective breastfeeding promotion program.

The authors conclude, "Findings suggest that breastfeeding among women with limited income may be increased through a variety of methods, including using the influence of family and friends in interventions, providing incentives for breastfeeding, providing direct assistance after birth, and avoiding the routine distribution of formula gift packs."

Haneuse S, et al. 2000. Factors influencing breast-feeding rates among Arizona WIC participants. American Journal of Health Behavior 24(4):243-253.

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4. REPORTS DISCUSS RISKS OF ADOLESCENT EMPLOYMENT AND FARMWORKING

Each year in the United States between 60 and 70 adolescents die from work-related injuries, hundreds more are hospitalized, and tens of thousands require treatment in hospital emergency rooms, states a fact sheet by the National Institute for Occupational Safety and Health (NIOSH), of the Centers for Disease Control and Prevention. The rate of deaths attributed to the leading causes of work-related fatalities (motor vehicle injuries, job-related homicide, and injuries associated with machinery) for 16- and 17-year-old workers is comparable to or higher than the rate for adults. The fact sheet discusses NIOSH reports on six recent adolescent-worker deaths across a variety of industries (including farmworking, amusement park labor, campground labor, warehouse labor, and construction). It also states that "too often, as illustrated by some of the cases in the recent NIOSH fatality reports, youths under 18 are killed or seriously injured while working in tasks or jobs prohibited by child labor laws, such as operating heavy equipment."

A recent report by the international rights group Human Rights Watch highlights health and safety issues involved in adolescent farmworking. The report states that farmworking is the most hazardous occupation in the US. The authors, who interviewed migrant and seasonal farmworkers primarily in Arizona, note that it is difficult to estimate the number of adolescents working in US agriculture. The authors cite a recent US General Accounting Office report, which states that an estimated 300,000 15- to 17-year-olds work in agriculture in the US each year. The majority of workers interviewed for the report began working in the fields between the ages of 13 and 15.

The report highlights these health and safety concerns:

• Exposure to pesticides through direct or secondary sources;
• Poor sanitation, often due to lack of toilet facilities, handwashing facilities, and drinking water;
• Work-related injuries from knives or heavy machinery; and
• High rates of depression and substance abuse.

The report concludes that laws like the Fair Labor Standards Act do not adequately protect children. It states that children working on farms may be employed at a younger age (12 instead of 14) than those working in other areas, and there is no limit to the number of hours they may legally work. The report issues a series of recommendations for Congress, the Department of Labor, the Environmental Protection Agency, and states.

A fact sheet by the Department of Labor (DOL) focuses on a safety program for adolescents in summer employment called "Work Safe This Summer." The program is a partnership between DOL, NIOSH, the American Academy of Pediatrics, and the National Consumers League. The program includes an employer's guide to adolescent worker safety and an adolescent worker's bill of rights.

US Department of Labor. Work safe this summer: Learn a lesson for life. Available at <http://www.dol.gov/dol/teensafety.htm>.

Human Rights Watch. June 2000. Fingers to the bone: United States' failure to protect child farmworkers. Available at <http://www.hrw.org/reports/2000/frmwrkr/>.

National Institute for Occupational Safety and Health. Teen worker fatalities in diverse industries show importance of injury prevention efforts. Available at <http://www.cdc.gov/niosh/teenfatl.html>.

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5. GAO REPORT FINDS THAT NIH STUDIES INCLUDE WOMEN IN RESEARCH BUT DO NOT ANALYZE BY SEX

Last week's MCH Alert included a piece that summarized an article from the Journal of Women's Health & Gender-Based Research, which found a lack of analysis by sex in studies funded by the National Institutes of Health (NIH). The Alert piece raised questions about the specific nature of women's representation in such studies. A May US General Accounting Office (GAO) report may help to answer some of the questions about the inclusion of women in NIH clinical trials and whether researchers are analyzing by sex. The GAO report examined NIH's progress in conducting research on women's health and found that "NIH has made substantial progress in ensuring that women are included in studies but less progress in encouraging analysis by sex."

Findings include the following:

• More than half of the participants in clinical research studies NIH funded in fiscal year 1997 were women, according to NIH's tracking data. Even when studies with female-only or male-only protocols were removed from the analysis, the proportion of women enrolled was greater than 50%. Aggregate enrollment data for all extramural research protocols funded in fiscal year 1997 show that 61.9% of the study subjects were women and 37.1% were men. Minorities were also found to be well represented.
• NIH's spending on women's health has increased, and it has grown more than overall spending. Determining the amount spent on women's health is complex, however, and the data must be interpreted with caution.
• Progress in carrying out the 1993 NIH Revitalization Act's requirement that clinical trials be designed to permit analysis of whether interventions affect women and men differently has been slower than progress in implementing other aspects of the inclusion policy. The Revitalization Act exempts certain clinical trials from this requirement (i.e., when substantial scientific data demonstrate no significant difference between women and men).

The authors of the GAO report looked at published literature to determine whether analysis by sex was occurring. They note, however, that not all such analyses are published. They write, "NIH officials told us that when an analysis reveals no difference in outcome, journals publishing the analysis may omit this information because editors often discourage researchers from including 'no news' information in their results." The NIH officials also stated that "because researchers who received funding after the new guidelines took effect are just now beginning to publish their study results, the amount of analysis by sex may increase."

US General Accounting Office. 2000. Women's health: NIH has increased its efforts to include women in research (GAO/HEHS-00-96). Washington, DC: U.S. General Accounting Office. The report can be downloaded from <http://www.gao.gov/daybook/000518.htm>.

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