Effective well-child care

Effective Well-Child

Care

Lucy M. Osborn, MD, MSPH I think there has been very little research . . . and it seems to me that evaluation would be aJirst step in any research eflort in relation to health services. In other words, we have to evaluate what we are accomplishing or at least what we think we are accomplishing. William

H. Stewart,

MD, the Fifty-sixth

Ross Conference, 1969.1

The Task Force notes that the value ofpreventive child health care has not been documented with scientiJic evidence; it has not been quanttjied, justified or documented to be costefictive. Task Force on the Effectiveness of Preventive Child Health Cam, the American Academy of Pediatrics, June 1982.’

The evidence on the efectiveness of components ofwell-child care . . . is more remarkable for its limitations than for its jbtdings. Office of Technology

Assessment,

February

1988.3

Policymakers, researchers, and clinicians have questioned the effectiveness of well-child care for many years. As the nation faces decreasing resources for health care, the cost-effectiveness of all medical interventions must be critically examined. Simultaneous provision of universal access to care and containment of costs can only be accomplished if basic benefit packages are defined in a way that confines the services available to those procedures and treatments that have proven benefit at reasonable costs. Disease prevention and health promotion are activiSupported by The David and Lucile Packard Foundation Center for the Future of Children. Lucy M. Osbom, MD, MSPH, is a professor of pediatrics at the University of Utah Health Sciences Center, Salt Lake City. CURRPROBLPEDIATR 1994;24:306-26. Copyright 0 1994 by Mosby-Year Book, Inc. 0045-9380/94/$4.00 + .lO 53/l/59796

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ties that normally require little technology and are therefore generally less expensive than the medical treatments they theoretically avert. However, the value of office-based preventive interventions, such as child health supervision, is generally unproved.3, 4 A crucial concept that must be accepted by health care providers is that preventive interventions require time and resources and are costs to the health care system if they do not result in improved outcomes and a lessening of the burden of disease. Such activities must therefore be critically examined and their outcomes assessed. For health care as a whole to be delivered effectively, each part must be efficiently and capably administered. It is incumbent on individual clinicians to consider their activities in terms of effectiveness. Providers can frame every visit as an “experiment of one,” in which they consider what needs to be accomplished during a visit, how they can achieve their goals, and what outcomes they can examine to know whether they have attained those goals.5 It is not surprising that little or no evidence has supported the efficacy of child health supervision as described by the American Academy of Pediatrics.6, 7 One Surgeon General has defined health promotion as “any combination of health education and related organizational, political and economic interventions designed to facilitate behavioral and environmental changes conducive to health.“’ It is obvious that protecting the health of children is a very complex issue. The well-child visit is only one small part of the much larger “crazy quilt” of prevention programs. Care for children is fragmented among the public and private sectors and a myriad of agencies. A coordinated approach and overview are sorely needed. The Maternal and Child Health Bureau and the Medicaid Bureau attempted to develop national

guidelines for health promotion and disease prevention that would provide such a framework. The Bright Futures Project was to recommend that preventive services be provided in multiple settings, including physician’s offices, schools, home and child care settings, and other community programs.’ Unfortunately, the project did not adequately delineate a comprehensive prevention program for children, but rather details a series of health supervision visits. As described by Green and Keuter in their book,

Health Promotion Planning: An Educationaland Environmental Approach,this is not an atypical outcome in the field of health promotion planning.8 They have discerned two pervasive fallacies in the development of health promotion programs: (1) Because providers are activists in their orientation, they have a tendency to begin with inputs rather than outputs. They often have predetermined the intervention strategies to be used before carefully considering the problem to be addressed. (2) They generally seem to have no consistent basis for choosing either the health issue to be addressed or the target population. Although the goal of healthy children is the starting point for both Guidelinesfor Health Supervision II and the Bright Futures Project, each begins with a predetermined intervention strategy, the child health supervision visit, rather than with the desired outputs. The Bright Futures Project attempts to develop a “contextual approach, ” but then, like the Guidelines, it outlines a series of visits designed to implement complex age-specific interventions targeting the entire population of children. To adequately understand and evaluate child health supervision, a different approach is needed, one that places office-based prevention strategies in the context of an overall plan. Not only would this create more realistic expectations of what can be accomplished through child health supervision visits, but it could also create a logical framework for defining productive, goal-directed roles for clinicians as direct providers of care, coordinators of services, and child advocates. Faced with the varied needs of children and diverse patient populations, practitioners, policymakers, and researchers need a method of conceptualizing and developing prevention programs rather than a specific set of recommendations. The purpose of this monograph is to provide such a conceptual framework. The monograph is divided into two sections. The first is a stepwise approach to health promotion planning. It begins with a needs assessment, progresses to program design and implementation, and concludes with program evaluation. Child health supervision is then defined as an office-based prevention strategy rather than a

series of visits. Basic concepts essential to preventive health care are then described. The second half of the monograph outlines the role of the pediatrician and other health care personnel and considers the practicalities of office-based prevention, including specific health objectives that can be accomplished in this setting, content, format, and measurable outcomes. The model is then applied specifically to those aspects of health deemed to be amenable to office-based intervention strategies. Through this stepwise progression of needs assessment, program development, and outcome evaluation, it is possible to develop a logical approach to child health supervision that is based on a unifying theory of care rather than diverse expert opinion. This approach will yield specific, testable hypotheses that can be researched. If studies then indicate a specific approach is not effective, the temptation to “throw out the baby with the bath water” could be resisted. The conclusion from such a result should not be that prevention is not needed but rather that different, more effective methods must be designed and tested.

PRECEDE and PROCEED: An Approach to Heath Promotion Planning and Implementation Lawrence Green and Marshall Kreuter’ have developed an effective method of health promotion and planning they call PRECEDE-PROCEED. The model includes two components. PRECEDE, an acronym for “Predisposing, Reinforcing, and Enabling Constructs in Educational and Environmental Diagnosis and Evaluation,” is a diagnostic or needs assessment phase. The second component, PROCEED, refers to strategies for intervention, policy development, and program evaluation. PROCEED stands for “Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development. ” This approach, described in Health Promotion

Planning: An Educational and Environment Approach,’ can be adapted both to the general design of prevention programs for children and to the specific evaluation of child health supervision. This logical, stepwise, technique, graphically illustrated in Figure 1, parallels that of medical diagnosis and treatment and can therefore be easily incorporated into clinicians’ concepts of care and its assessment. The vernacular used in this model, however, is that of health education rather than medicine and could therefore be confusing. Table 1 translates Green and Kreuter’s labels into medical terminology. PRECEDE-PROCEED incorporates biomedical and behavioral science theories to create new meth-

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PRECEDE Phase 5

Administrative and policy diagnosis

Phase 4

Phase 3

Phase 2

Phase 1

Educational

Behavioral and environmental diagnosis

Epidemiological diagnosis

Social diagnosis

and

organizational

-I

---

HEALTH PROMOlION

Behavior

Environment

I I

I

I I

Phase 6

Phase 7

Phase 6

Implementation

Profess evaluation

Impact evaluation

, Outcome evaluation

PROCEED FIGURE 1. PRECEDE-PROCEED model for health promotion planning. (Modified from Green LW, Kreuter MW. Health promotion today and a framework for planning. Health promotion and planning; an educational and environmental approach. Mountain View, California: Mayfield Publishing, 1991:1-43.Copyright 1991 with permission from Mayfield Publishing Company.)

TABLE 1. PRECEDE-PROCEED model for health promotion planning: Translation of health education terminology to medical terms Phase

Health education term

Phase 1 Phase 2

Social diagnosis Epidemiologic diagnosis Behavioral diagnosis

Phase 3 Phase 3 Phase 4

Environmental diagnosis Educational diagnosis

Phase 5

Administrative diagnosis Policy diagnosis

Phase 6 Phase 7 Phase 8

Process evaluation Impact evaluation Outcome evaluation

Medical term Desired outcome Targeted health problems Health-related behaviors Environmental factors Factors influencing health behaviors Preventive intervention Regulations affecting health Process evaluation Impact evaluation Outcome evaluation

ods for health education. Appreciation that the roots of disease are multifactorial has brought an understanding that more sophisticated techniques are needed for disease prevention. Common, simple proscriptions and advice giving, so prevalent in current

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office-based clinical prevention activities, are recognized as being unlikely to significantly alter the factors that affect health. The context of health and disease must be considered. Conditions that affect health can be categorized as (1) environmental factors, (2) biomedical factors, and (3) behavioral factors. Examples of environmental factors are the quality of the water, food, shelter, and air. Preventive interventions that involve these elements are generally in the purview of the public health system. An individual clinician has little influence over the conditions of living except as a political advocate for children. Biomedical factors include such conditions as a genetic propensity for early cardiovascular disease. Although clinicians may be able to promote healthy life-styles among individuals at high risk, screening for biomedical factors, such as hypercholesterolemia, and early treatment with medications are often much more effective interventions.“-” Finally, life-style factors such as smoking, alcohol, drug abuse, and physical activity are examples of risk factors for disease that are amenable to behavioral interventions and therefore amenable to intervention through office-based, individualized, health promotion activities.

The PRECEDE-PROCEED model is a framework for health promotion and disease prevention that places each of these factors in a broader context. It also provides a method for delineating the relationship of these factors for any given health problem. The steps in the model outline the causal chain of determinants of disease and consequences of health behaviors. The process begins with an analysis of desired outcomes in terms of the quality of life of the population or individuals and then explores the causal chain of health issues that threaten the targeted quality of life issues. After the potential health problems have been ascertained, the model continues with an analysis of the behavioral components of each health problem and the predisposing, enabling, and reinforcing factors of each behavior. The next step is the development of the health promotion program. Key indicators that are determined to be related to the health behaviors and desired outcomes determined in the PRECEDE process are then used as measures to evaluate the effectiveness of the program. No matter what level of intervention (primary, secondary, or tertiary) is being considered, these concepts envision health promotion programs as interventions that short-circuit illness or enhance quality of life either through changes in or development of health-related behavior and conditions of living. For child health supervision, this would include the essential elements of both behaviors of parents and their children and the environment in which children are being reared. The PRECEDE process reveals the multiple factors that shape health status and can help the practitioner focus on the needs of the family and the child. The PROCEED process provides a logical framework for intervention and evaluation of the therapy or program. Beginning at the End As previously noted, because providers are activists in their orientation, they have a tendency to begin with inputs rather than outputs and may have predetermined the intervention strategies to be used before carefully considering the problem to be addressed. Often the logic choosing the health issue to be addressed and/or the target population is not apparent, and seldom is it explicit. Currently available recommendations for child health supervision outline a series of complex interventions by age, targeting the entire population of children. These attempts to define the scope of child health supervision have only been undertaken in the past 10 years and are laudable. However, what is needed is a method that can be applied by practitioners and researchers to the populations that they

TABLE 2. Green and Kreuter’s

phase 1: Social diagnosis

Quality of life problems and priorities

of children

Social indicators: Physically sound and fit# Nurturing family and supportive relationships with others# Community environment that promotes social responsibility and cultural diversity Physically safe, secure, environment# Adequate family income, shelter, nutrition, and housing Access to coordinated, comprehensive health care# Quality education Development of positive, basic, moral values Coping repertoire that mitigates stressful life events High self-esteem, sense of efficacy, and belief in ability to achieve personal success Good social skills, development of personal social network #Indicates social indicators theoretically amenable, at least in part, to office-based prevention strategies. Data from Bright Futures: Nutional Guidelines for Health Supervision of Infants, Children, and Adolescents’ and Beyond Rhetoric: A New American Agenda for Children and Families.‘3

serve rather than a series of specific recommendations. The PRECEDE framework directs initial attention to outcomes rather than inputs. In this case that means defining the desired effects of a prevention program for children rather than starting with the concept of “well-child care.” Beginning with the end means considering what the desired outcomes are before planning any program or intervention. The first five phases are a needs assessment related to the health status of a population and the factors that contribute to health and disease. The desired outcomes are defined in terms of social, epidemiologic, behavioral, and environmental terms (Figure 1). The educational and organizational factors that contribute to the health behavior are then considered, as well as the administrative and the policv issues. It is not until the sixth phase of the model-that implementation (treatment) occurs. The last three phases essentially repeat the first three; instead of focusing on the diagnosis of the problem, these steps reexamine the factors determined to be important and use them to create the program evaluation, including process, impact, and outcome evaluation. Table 2 graphically demonstrates the first phase in the planning of a health promotion program for children, again starting with the desired outcomes rather than the treatment. The process can also be used for planning age-specific health promotion visits or for planning a stepwise approach to a specific health issue, such as the quality of the child’s family environment. The first phaseof plan-

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ning involves consideration of the ultimate outcome, quality of life, thorough examination of the problems of the target population, in this case children. Quality of life is generally defined in social terms and is subjectively defined by communities and individuals. Those factors listed in Table 2 have been condensed from documents prepared by the Bright Futures Expert Panels and the National Commission on Children. l3 For individual health practitioners, determination of the quality of life would involve ascertaining the needs of the patients they serve. The process of office-based determination of community needs is gaining recognition in the practicing community. Techniques for this kind of needs assessment can be found in the Community Oriented Primary Care (COPC) literature.14,15 For the researcher, this first phase requires definition of a pertinent population (e.g., those attending a particular HMO or living in a particular census tract). Without this kind of specificity in defining the study population and its problems, any research in preventive interventions is doomed to show that the program is not effective. One simply cannot expect that the families of poor children living in inner cities and those in middle-class suburbs will have the same quality of life issues or that they will be able to respond to similar interventions. Once the desired social outcome and the problems that contribute to any determined gaps between outcome and reality have been determined, the practitioner or researcher would begin phase 2. This process is one that identifies the specific health issues that may contribute to the social problems noted in phase1. An example of this process would be determination by a practitioner or community that a critical factor in the quality of life for every child is a safe environment. This would include safety within the community from violence and accidents and safety within the home from both accidental and nonaccidental trauma. Phase 2 for community planners would involve identifying the specific problems within their community. For children living within the inner city, the key problems may be random violence such as gunshot wounds. For children in middle-class suburbs, they may be injuries from bicycle accidents. The issues are obviously quite disparate and would involve different community-based interventions. For the individual pediatrician, an assessment of children’s exposure to violence or accidents in the home would be most appropriate. He or she may wish to screen patients for risk factors known to be associated with these problems or may want to de-

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termine from billing records the incidence and types of accidents among those cared for. Phase 3 consists of identifying specific healthrelated behavioral or environmental factors that can be linked to the health problems chosen as being most deserving of attention in the previous phase. In this example, the random violence and gunshot wounds in an inner city may be related to drug abuse among those living within the community. In the case of the suburban children an excess of injuries from bicycle accidents might be from failure to separate automobile from bicycle traffic or from lack of a helmet law. In the case of the individual practitioner an excessive rate of accidental trauma among his patients could be related to any number of factors, such as the temperature of the water in the homes or the presence of medications dispensed without safety caps. Research on health and social functioning indicates that there are hundreds of factors that have the potential to influence a given health behavior. Phase 4 examines the predisposing, reinforcing, and enabling factors that contribute to the targeted behavioral and environmental components. Only after completion of the first four stages of the process can determinations be more accurately made regarding the appropriate level at which an intervention should be made. Even with accurate information, it still may not be obvious which methods (e.g., legislation versus a targeted intervention) will be the most effective. Child health supervision, as a specific intervention strategy, does not enter the algorithm until phases5 and 6. In our examples relating to safety, clinicians would be generally more effective as advocates than as providers of care. Individual practitioners cannot expect to change the incidence of shootings through office-based interventions. However, they can lobby for legislative intervention for gun control and can be advocates for creation of community programs such as drug treatment centers. Counseling children regarding pedestrian and bicycle safety is not as effective in changing these behaviors unless included as a part of a wider community campaign.i6 The last three phases use the fac:ors outlined in the first four phases of the process for evaluation. Evaluation of whether the program (in this case child health supervision) has been implemented and its effects on predisposing, enabling, and reinforcing factors is process evaluation. Examination of the program’s effects on the behavioral, life-style, and environmental factors is impact evaluation, whereas the results of the program on health and quality of life are outcome evaluations.

Child Health Supervision as a Prevention Program As demonstrated by the introductory quotes, over the years many have questioned the effectiveness of well-child care. Although the paucity of research on the subject contributes to the continuing criticism of child health supervision, the benefits of office-based prevention strategies should be questioned. As demonstrated by the examples given above, many of the diseases of childhood are more effectively dealt with legislatively or with programs sponsored through other agencies such as public health departmen&l7 Still, there are many theoretically sound reasons for continuing to use community clinics and private physicians’ offices for delivery of services to children. Unfortunately, because the effectiveness of care is often confounded by and confused with the issue of access to care, policymakers have often minimized office-based services as a method of reaching the pediatric population. In fact, the physician’s office is one of the few regular points of contact between young children and any organized system of care. Currently, 80% of children receive their medical care either through a private physician or an HMO.” The potential for office-based health promotion programs is therefore present for all but a minority of the pediatric population. Although special services must be offered to the most vulnerable population that does not receive care from a personal physician, denial of resources to those who do receive regular care ignores the needs of the overall population of children. One of the greatest fallacies in program planning for child health is the common assumption that children of middle-class and upper-class families have few health problems and that when they do, they have access to the appropriate care. The dearth of needs assessments of middle-class families supports this assumption. These are the children for whom the average pediatrician attempts to deliver office-based interventions. A recent study of preventable and treatable psychosocial problems compared families and “low-risk” settings.l’ The seen in “high-risk” incidence of psychosocial risk factors was significant among both groups, and although children in highrisk families had more identifiable issues per child, the actual burden of preventable problems was much greater among those in “low-risk” settings because they represent a much larger proportion of children. Another reason to use office-based prevention tactics is continuity of care. Other systems, such as the educational system or the workplace, offer ser-

TABLE 3. Leading causes of death of children ages 1 to 24 years 1. 2. 3. 4. 5. 6.

Accidents and adverse conditions Homicide Suicide Neoplasms Infectious diseases Cardiovascular diseases

vices or provide contact for specific personal epochs, whereas contact with the health care system is likely to occur over a lifetime. An additional rationale for office-based care is that with their extensive knowledge of both mental and physical factors that affect children, health care providers are in an excellent position to assess the need for intervention and to organize services that span disciplines and geography. Although multiple factors make the idea of using the health care system as a point of delivery of services attractive, caution must be used with this approach. An unreasonable dependence on this system has evolved because modern American society has refused to fund programs that could more logically and effectively address adverse circumstances that affect children. Certain conditions have been “medicalized” so that the providers of care can be reimbursed for their services. The level of violence and its toll on children is an example. Violence cannot be prevented by the delivery of health care, only its aftermath can be treated medically. ” Expectations that clinical preventive care can cure the ills of society are not only unrealistic, but they also obscure the more modest, but still essential, tasks that can be successfully performed in an office setting. Although child health supervision can be logically supported for the reasons cited above, the quality of life outcomes proposed by the Bright Future Panels and others (Table 2) indicate that those conditions amenable to office-based preventive interventions are limited. Table 3 lists the commqn causes of death for children and adolescents aged 1 to 24. Few, if any, can be effectively addressed even by the most motivated practitioner.

So, Is There a Role for Office-Based Prevention and Can This Kind of Intervention Be Effective? Those aspects of care that can only be influenced by one-to-one or small group interactions are ones that must be delivered through primary care providers. One example is that personal care is necessary to effectively address one of the most important contibutors to the well-being of children: the parent-child re-

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lationship. Every study that has attempted to investigate factors that predict the eventual success or failure of children has found that the key ingredients are stability of the family, the family’s value on education, the emotional environment of the home, and the relationship of the child to the important adults in his or her life.21, 22 Preventive mental health programs depend on the formation of a personal relationship between the recipient of services and the care provider. In pediatrics the possibilities for positively influencing the emotional environment of children most commonly occur during health maintenance visits. Theoretic models of factors that produce emotional and behavioral disorders suggest that effective office-based programs can influence a child’s environment. The continuum of child care ranges from an ideal environment, in which the needs of even the most distressed child can be met, to Winnecott’s concept of the “good enough parent” who provides an adequate milieu for most children, to the poorest, most disorganized environment in which even the most capable of children will flounder.23 Outcomes will depend on the balance of risk and protective factors. Risks include the number of stresses in the wider environment, the number of risk factors in the family environment, the vulnerability of the child, and the timing and nature of particular experiences. Protective factors include the resilience of the child, the quality of the home environment, and the support systems of the wider environment.24 Not only can pediatricians assess the child, the family, and the environment, they can also provide counseling that can contribute to healthier parent-child relationships. In determining the kinds of interventions that can be made, it is important to remember that the overwhelming burden of psychosocial problems does not occur in what would be considered high-risk families but rather in the average family that does make routine visits for child health supervision.l’ Because these families are not overwhelmed by poverty and multiple problems, they may also be more amenable to primary preventive interventions and secondary measures such as early diagnosis and treatment. In keeping with the principle that effective preventive programs should be targeted to those most likely to benefit, the families and children seen in the office setting are a population that should be targeted for psychosocial prevention programs. In the second portion of this article, the PRECEDE-PROCEED model will be applied to child health supervision and those aspects of prevention, including parent-child relationships, that appear to be amenable to office-based prevention strategies.

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Key Concepts for the Delivery of Preventive Health Programs Although pediatricians have been advocates of prevention and spend from 25% to 50% of their time in what is considered preventive activities (well-child care, child health supervision),25 few have received any formal training in preventive medicine.2 Although medical schools have provided outstanding patient care, research, and education in acute and chronic medical care, they have dedicated few resources toward those activities in the area of prevention.26 Protection of the public’s health and disease prevention has been delegated to an underfunded public health system. Students have almost no contact with public health programs, and few research dollars have been channeled to the system. Consequently, compafed with the basic sciences and clinical care, relatively little is known about effective preventive health care, particularly in relationship to traditional medicine and office-based practice. One of the exciting possibilities of health reform is that it presents a unique opportunity to address this problem. The concepts of integrated health systems in which physicians’ offices, hospitals, and insurance products are aligned to care for specific enrollees means that those involved in the delivery of traditional medical care will be responsible for a specific population of patients rather than a group of individuals. If the information system used to link delivery sites in integrated systems is designed to gather pertinent clinical data rather than only economic and insurance facts, an exciting new era of research in preventive health care can begin. Physicians who participate in such plans will have a uni ue opportunity to begin to examine their practices. 17 The simultaneous attempts to provide universal access to care and to contain costs can only be successful if all health activities are carefully scrutinized and only those that are shown to be effective are implemented on a wide-scale basis. It is essential, then, that those who are trying to offer services to children understand the key concepts of prevention.

Primary, Seconday, and Tertia y Prevention Over the years the concepts of prevention have changed to include not only prevention of specific diseases but also prevention of disability among patients who have already been affected by a condition. Primary prevention is defined as interventions designed to reduce the incidence of a particular disorder in a target population and includes both health promotion and disease prevention. The most effec.tive prevention programs target “at-risk” populations, in which the incidence or prevalence of the condition is relatively high. The purpose of primary

preventive activities is protection and enhancement of health. In child health supervision, disease prevention (such as immunizations) and health promotion (such as nutritional counseling and parenting education) are both considered primary prevention activities. Secondary prevention is directed toward a population that is already known to have a particular condition and includes early disease identification and treatment. The purpose of these activities is the same as that for primary prevention, but these activities are related to protection from the sequelae of the condition and enhancement of function. Finally, the concept of tertiary prevention is related to enhancement of functioning of patients with chronic conditions through rehabilitation. Screening Principles. Screening for preventable conditions is one of the essential activities of any prevention program and, as will be described in the section discussing specific health maintenance visits, should be an integral part of such care. Pediatric health care providers should try to detect those conditions that are amenable to prevention at any level. Because many times the treatment will require referral to other agencies, it is logical that pediatricians retain responsibility for this function. With their knowledge of social systems and their scientific training, health care providers are qualified to perform the screening; to institute treatment; and, when necessary, to make appropriate referrals. Screening, technically, is population-based and attempts to diagnose conditions among basically healthy groups of people. Activities that are undertaken in an office setting are more appropriately termed “case-finding, ” because the clinician is able to gather other information that can increase the efficiency of screening procedures. For example, he or she may decide to forgo the recommended routine screening test if a patient has no known exposure to lead but will test when there is reason to suspect that the level might be elevated.28 In so doing, the physician is separating patients into subpopulations, one in which the prevalence of disease is low and another in which it is high. Because, as explained below, the characteristics of screening tests depend highly on the prevalence of disease in the population tested, this greatly affects the test’s exactness. The basic principles of screening are as applicable to case-finding as to community screening. These are (1) The disease should be common enough to warrant a search for its risk factors or latent stages. The cost/benefit ratio of screening for rare diseases may not be acceptable. (2) The mortality or morbidity from the untreated condition must be substantial. (3)

Screening should generally be done only for conditions that can be ameliorated by early diagnosis and treatment. For this condition to be meet, diseases must have a preclinical stage, must be detectable through the use of a test that is accurate, and must have treatment available that is acceptable and results in better outcomes when used in a preclinical phase than therapy given after symptoms develop. (4) Screening tests must be highly accurate with good sensitivity and specificity. The tests should be acceptable to the population and suitable for routine application. 29, 3o Crucial to understanding screening are the confusing concepts of sensitivity and specificity. These terms are characteristics of screening tests, and apply to laboratory data, as well as other information such as that gathered during a history or physical examination. Sensitivity is the proportion of individuals with the disease who are detected by the test (Sensitivity = True positives.) True positives + False negatives Specificity is the proportion of individuals without the disease who will be correctly categorized by the test (Specificity = True negatives.) True negatives + False positives One of the reasons that these concepts often confuse health care providers is that they are critical in selection of a test but not in the interpretation of results. Providers seldom are required to use the concepts of sensitivity and specificity in their daily work but are very dependent on derivatives of these test characteristics: the positive and negative predictive value of a test. The positive predictive value is the proportion of patients with positive test results who have the disease, whereas the negative predictive value is the proportion with negative test results who do not have the disease. Predictive values depend both on the characteristics of the test and on the prevalence of the disease in the population. As the specificity of a test increases, the greater the negative predictive value will be (i.e., the better the test, the more the practitioner can believe a negative result). The more specific the test, the less likely an individual with a positive test result will be free of disease. Thus, if the test indicates a patient has the disease, a physician can have more confidence that the patient is affected with a highly specific test. However, with relatively uncommon conditions, the major factor relating to the positive predictive value is the prevalence of the disease in the population. The level of assurance with which the provider can report the results to the patient depends on

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TABLE 4. Comparison of positive and negative predictive values of a test with sensitivity of 0.9 and specificity of 0.9 when prevalence of disease is 30/1000 and 200/1000 Test status Disease status

Positive

Negative

Values when disease prevalence is 30/1000 27 3 Disease 97 873 No disease 124 876 Total Values when disease prevalence is 200/1000 178 22 Disease 89 711 No disease 267 733 Total

Total 30 970 1000 200 800 1000

whether he or she has accurately selected a population to test. Because in “case-finding” the provider is using other information to make decisions regarding whether a test is indicated, the practitioner actually targets a population with a higher prevalence of the disease, thus increasing the specificity and positive predictive value of the tests he or she orders. A vivid example is the interpretation of a positive screening for AIDS. The screening test is highly specific, yet, if the disease is relatively rare among the group of patients tested, those with positive test results are far more likely to have a falsely positive test result than to have the disease. Thus only improvement in the accuracy of the test can improve the sensitivity and negative predictive value, but selection of a population with a higher prevalence of disease for screening will increase the specificity and positive predictive value. Table 4 illustrates this by indicating the actual numbers of patients with falsely positive test results when, with a test sensitivity of 0.9 and specificity of 0.9, the prevalence of disease increases from 30/1000 to 200/1000. In the first case 124 of 1000 screened patients would have positive test results. Of these, only 27, or 22%, would actually have the disease. When the prevalence is 200/1000, however, 178 patients of the 267 with positive test results (67%) will have the disease. As the elements of preventive care are being studied, the effectiveness of the child health supervision visit for screening should be one of the outcomes examined. The questions that should be considered are: (1) Can effective screening be accomplished during a well-child visit? Are the positive and negative predictive values of the provider’s activities cost-effective? (2) If a positive screen is obtained and the patient is either asked to return or is referred for treatment, how often is the treatment accepted and pursued? (3) I4 treatment is provided, does it lead to improved outcomes for the patients?

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Guidelines for Effective Prevention Programs Minimum guidelines for producing effective prevention programs have been developed.31 Many of the problems with proving or disproving the efficacy of child health supervision can be more easily understood if it is considered as a prevention program applied to the population of children rather than a series of visits to the pediatrician. As the reader will rapidly see, child health supervision, as currently practiced, does not meet any of the criteria for effective programs. This does not mean that this practice should be abandoned; rather the delivery of wellchild care should be reconsidered.

ProgramsMust Be Basedon the Available Scientific Evidence. Whenever possible, randomized trials should be conducted to prove the worth of programs. The same rigorous criteria that are ideally used to determine clinical practices should be applied. Although such trials are expensive, they should be costeffective compared with the potential waste of inadequately tested interventions and the continued burden of potentially preventable disease that is not being effectively addressed. Well-child care dramatically illustrates this point. This activity consumes between 25% and 40% of pediatricians’ time. If it is not effective, this is a tremendous waste of both physicians’ and patients’ time. This has remarkable economic implications both for health manpower and time lost from work for those parents who must leave their jobs to receive the intervention. Unfortunately, trials of preventive interventions are methodologically difficult, and because proof of the efficacy of a prevention strategy involves showing that a disease or condition does not occur, these studies will usually require larger numbers of participants than clinical ones. In the case of well-child care, randomizing children to a “no well-child care group” would not be acceptable. However, various elements of child health supervision can be studied in this manner, particularly because only guidelines exist. Once therapies have been adequately investigated and standards of care are developed, randomization into no-treatment groups would be unethica1.32 Finally, the potential for natural experiments does not exist because the population that either cannot or chooses not to seek preventive care will be intrinsically different from the population that does.

Prevention Programs Should Be Supportedby Effective Data Systems. Even after a disease is determined to be appropriate for screening and intervention after valid tests are available, it will still be unclear whether

a general screening program should be implemented. Proposed programs should be examined for both feasibility and effectiveness. Feasibility is determined through a number of measures including the acceptability of the program to those who will be screened, cost-effectiveness, the yield of cases, and the subsequent diagnosis and treatment of individuals who is measured have positive tests. Effectiveness through the reduction of morbidity and mortality from the disease. To measure these two factors, effective data systems must be in place. Because of the costs of examining large populations, particularly with reference to well-child care, the information systems must feature data entry by the patients themselves, receptionists, or nurses. Methods of data retrieval must also be developed. The lack of appropriate data collection systems is one of the primary reasons that good outcomes research on the effectiveness of office-based prevention programs is virtually nonexistent. Programs Should Be Targeted to the Recipients Most in Need and Those Most Likely to Be Able to Benefit From the Intervention . Because health resources are not infinite and because preventive programs can be costly, their negative effect often not known, and their impact on different groups varied, programs should be targeted to those populations that are most likely to benefit. Definition of these populations includes quantification of risk and consideration of ability to comply with programs. This is another strong argument supporting the continuation of office-based prevention programs. Not only do 80% of children have contact with this portion of the health care system, their families, by bringing their children to the provider, have already demonstrated their ability to access the health care system. One can therefore hypothesize that the likelihood they would follow through with recommended treatments and therefore benefit from an intervention is increased over those who cannot access even acute care services. Health Promotion Activities That Improve the Functional Status of Either Individuals or Populations Have the Greatest Potential for Cost Savings to the System. This concept is true whether the activity is related to primary, secondary, or tertiary intervention. Thus an exercise program that assists patients with degenerative muscular or neurologic disease to remain ambulatory longer not only saves health care costs but also may allow continued productive employment. This concept will be expanded in considering the effects of parenting interventions during well-child visits.

Programs Should Be Flexible. To provide widespread prevention programs, there must be enough flexibility in delivery sites, hours that programs are offered, availability in multiple languages, and simplicity of instructions. When considering outcomes research in prevention, however, increasing flexibility leads to greater difficulties in controlling variables and will introduce more possibilities for measurement errors. Each of these factors also represents a significant threat to the average pediatrician’s ability to deliver effective care. Although care is given at multiple sites and community physicians can offer extended hours, language and cultural barriers can be significant. Simplicity in instructions and in programs is also difficult because of the extensive scope of the goals for prevention in childhood. Programs Should Be Continuous. Preventive programs should be conducted on a continuing basis. It is well known that personal preventive behaviors, such as cessation of smoking, may not persist. At the same time, effective preventive programs are all too often doomed by their own success. An excellent example of this is immunization programs that have essentially eradicated many of the infectious diseases of childhood. Complacency of policymakers in refusing to fund universal immunizations, of parents in not bringing their children in for their immunizations, and of providers in delaying immunizations for minor illness has led to an alarming decrease in immunization rates among preschoolers.33 Programs Must Be Sensitive to Ethical Issues. Ethical and cultural considerations are central if any public policy or program is to be effective. In the realm of public health programs the balance of rights and needs of individuals and communities must be respected. Issues of privacy and of equity and justice in resource allocation will always be factors. Avoiding paternalism is of particular importance in preventive programs. As Dr. John Last has pointed out: “There is a long tradition of advocacy by public health workers, but in the past this may have been as often associated with preaching as with teaching.“34 Programs Should Muster a Variety of Community Resources. Many of the threats to the well-being of children are complex and often require time or expertise beyond the capabilities of the practicing physician. The pediatric provider can effectively screen for risk factors and coordinate care but must also know how to access and mobilize community groups and programs.

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Effective Prevention Requires Legislative Action and Social Policy Decisions. Many of the most effective prevention strategies require legislation or changes in public policy. Physicians can be among the most effective advocates for children. Involvement in the formulation and implementation of policy may have more far-reaching effects than anything an individual physician can do within the office setting.

Content and Format of Child Health Supervision Visits One of the difficulties facing providers who deliver well-child care is that the structure of a preventive health visit does not fit the traditional format that physicians are taught to use for other types of medical encounters. The “chief complaint” is always “well-child care”-which should not be a complaint if it is true! The “history of present illness” is equally inappropriate because the child is presumably well at the time of the visit. Prevention, particularly in childhood, must be considered a constant, ongoing process. Therefore preventive visits must be described both in terms of the individual visit and within the context of continuing care. The components of individual preventive care visits will first be described. The PRECEDE-PROCEED model of health promotion planning described above will then be used to place prevention visits in the context of an overall health promotion program. Most practitioners will be unfamiliar with the concepts and terms used by Green and Kreuter.* Reference to Figure 1 will help by providing the reader with a visual framework. The terminology used by health educators is similar to that of medicine but may be confusing to practitioners because the connotations are different. The names of the various “phases” or steps in the model will therefore both be explained and translated to more traditional medical terms. Table 1 is a list of “translated” terms. The individual preventive visit can be conceptualized as having three separate components: screening, health promotion and disease prevention, and patient management and follow-up. As outlined in the discussion of principles of prevention, screening is the application of a test to people who are asymptomatic for the purpose of classifying them with respect to their likelihood of having a particular disease or having a particular disease develop. The process of screening does not accurately diagnose illness but rather defines a population that should be further evaluated. In the well-child visit routine activities that can be considered screening procedures include gathering of historical data, physical examination including vision and hearing testing, observation of the pa-

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tient and his or her parents, and laboratory testing. Screening questionnaires that parents can complete in the waiting room have been shown to be usefu1.35 Health promotion and diseaseprevention typically involve consideration of the population as a whole in the context of everyday life rather than focusing on individuals at risk for specific diseases and is directed toward the determinants or causes of health and disease.36 Health promotion activities should be determined by the objectives of a prevention program. In considering well-child care as a method of delivering preventive services, there will be goals for the population as a whole, as well as goals for the specific population that an individual practitioner serves. In the PRECEDE-PROCEED model the first step, phase 1, is labeled “social diagnosis.” This term describes the quality of life outcome or desired health outcome that a program will address. These should be determined through needs assessment or problem identification. In the following paragraphs the outcome of access to quality health care will be used as an example. Patient management and follow-up is the portion of the visit in which care is coordinated. If no problems are detected during the screening procedures, the clinician can progress to health promotion counseling. If, however, a problem is diagnosed that needs intervention, the provider must make decisions regarding the need for treatment, the urgency of the problem and the timing of the treatment, what the treatment should be, and who should provide the treatment. As the provider assesses various aspects of health, this process is repeated multiple times during a visit. In pediatrics this is complicated further by the continuing development of children. Although these distinctions may seem selfevident and irrelevant to everyday practice, this conceptualization of the components of care can help practitioners ensure that every patient receives the preventive care he or she needs. All too often in practice the health promotion activities of a well-child visit are subverted because an interim history provides a positive “screen,” indicating a condition that requires intervention. If the visit is “converted” to an acute care or intervention visit, the family should be asked to return for the preventive visit. Universally poor immunization rates in the United States are partially explained by failure to immunize children who are ill at the time of a well-child visit and are not being asked to return for follow-up preventive care.33 As indicated in Table 2, the quality of life issues that can be addressed through office-based prevention activities are limited. Determination of factors that can be addressed and a definition of the related health objectives leads to a more logical approach to

TABLE 5. Healthy People 2000 objectives that may be amenable to office-based prevention strategies [services]

TABLE 6. Phase 3: “Behavioral and environmental diagnosis”

Objectives related to assurance of access to coordinated, comprehensive health care 14.16 Increase to at least 90% the proportion of babies aged 18 months and younger who receive recommended primary care services at the appropriate intervals. 17.15 Increase to at least 80% the proportion of providers of primary care who routinely refer or screen infants and children for impairments of vision, hearing, speech and language, and assess other developmental milestones as part of well-child care. 6.14 Increase to at least 75% the proportion of providers of primary care for children who include assessment of cognitive, emotional, and parent-child functioning, with appropriate counseling, referral, and follow-up, in their clinical practices. Care for the physical aspects of heakh 2.4 Reduce growth retardation among low-income children aged 5 and younger to less than 10%. 11.1 Reduce asthma morbidity among children aged 14 and younger, as measured by a reduction in asthma hospitalizations to no more than 225/100,000. 11.4 Reduce the prevalence of blood lead levels exceeding 15 kcg/dl among children aged 6 months through 5 years to no more than 500,000 and 0 respectively. 13.1 Reduce dental caries (cavities) so that the proportion of children with one or more caries (in permanent or primary teeth) is no more than 35% among children aged 6 through 8 and no more than 60% among adolescents aged 15. 20.3d Reduce hepatitis B virus (HBV) among children of Asians/Pacific Islanders to an incidence of no more than 1800 cases. 20.9 Reduce acute middle ear infections among children aged 4 and younger, as measured by days of restricted activity or absenteeism, to no more than 105 days per 100 children. 2.10 Reduce iron deficiency to less than 3% among children aged 1 through 4 and among women of childbearing age. 3.5 Reduce the initiation of cigarette smoking by children and youth so that no more than 15% have become regular cigarette smokers by age 20. 3.8 Reduce to no more than 20% the proportion of children aged 6 and younger who are regularly exposed to tobacco smoke at home. 20.11 Increase immunization levels Provide a physically safe, secure, home environment 9.5 Reduce drowning deaths among children aged 4 and younger to no more than 2.3/100,000. 9.6 Reduce residential fire deaths among children aged 4 and younger to no more than 3.3/100,000. 9.8 Reduce nonfatal poisoning among children aged 4 and younger to no more than 520 emergency department treatments per 100,000. Supporting families so that the child is in a nurturing environment 6.3 Reduce to less than 10% the prevalence of mental disorders among children and adolescents. 7.4 Reverse to less than 25.20000 children the rising incidence of maltreatment of children younger than age 18.

This table outlines some of the patient behaviors and environmental factors that can be addressed through the child health supervision to influence access to care and use of care. Behavioral factors related to access to care Formation of a therapeutic alliance Familial assumption of responsibility for health behaviors Parental use of provider as a resource to access beneficial services Child’s eventual assumption of personal responsibility for health Environmental factors related to access to care Office accessible both geographically and for extended hours of service Availability of providers Office environment comfortable, familiar, nonthreatening Staff perceived as approachable and helpful Time of wait for appointments Waiting room time Time required for provision of services

defining realistic content for visits. This is the first step in the PRECEDE-PROCEED model. Four issues that may be most amenable to intervention through child health supervision

visits are (1) assurance of ac-

cess to coordinated, comprehensive health care; (2) care for the physical aspects of health (e.g., diagnosis and treatment of illness, screening and intervention for threats to physical health, and promotion of physical fitness); (3) provision of a physically safe, secure, environment; and (4) helping families provide a nurturing environment through counseling and referral when necessary. The second phase in the PRECEDE-PROCEED

model is “epidemiologic diagnosis.” In this phase the health problems of the target population are defined. Such an assessment should reveal which health problems are important, determined objectively (rather than subjectively

as perceived

quality

df life), and

should ascertain those behavioral and environmental factors that contribute to the described health problems. Healthy People2000 outlined specific national health promotion and disease prevention objectives.37 Although many of the desired outcomes for children require intervention at a more global level, a significant number depend on individualized care. Table 5 lists the Healthy People 2000 objectives that are directly related to the quality of life issues that can be addressed through child health supervision. To plan what should be done during an actual visit, each of the related health outcomes should be considered in terms of patient behaviors and environmental factors that can be linked to the targeted Current Problems in Pediatrics / October 1994

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TABLE 7. Educational and organizational diagnoses: Factors that influence patients’ behavior regarding access to care and formation of a therapeutic doctor-patient relationship

Predisposing factors Previous Parental Parental Parental Parental

Therapeutic provider-patient relationship

experiences with the health care system education stress values, beliefs, and attitudes confidence

No. of families who voluntarily change providers in a 12-month period No. of inappropriate acute care visits, after-hours, and emergency services used by patients in the practice in a 12-month period No. and appropriateness of calls to the office

Enabling factors Communication Provider’s acceptance, empathy, Adequate time for interaction Availability of resources Health insurance

Family assumption of health care behavior

and competence

No. of child health supervision visits completed Completeness and timeliness of immunizations

Provider as a resource for accessing other services

Reinforcing factors Positive experiences with care Collaborative decision making Successful interventions, particularly Peer and family support

No. of patients referred for prophylactic dental services No. of Head Start-eligible children referred and enrolled behavioral

ones

health problem. The next step is to determine factors that influence behavior or contribute to the environment. Green and Kreuter’ label this step “educational and organizational diagnosis.” Because there are literally hundreds of potential influences on behavior, these factors are grouped and categorized into predisposing, enabling, and reinforcing factors. Careful assessment of each of these “diagnoses” can lead to the enumeration of related indicators that can be used to measure the outcome and impact of a health promotion program. Because the value of the health supervision visit has not been adequately appreciated for its role in ensuring access to coordinated, comprehensive health care, the following uses this concept to illustrate application of the model to this specific outcome. Tables 6 and 7 describe some of the behavioral, environmental, educational, and organizational factors that are related to access to care. Table 8 lists “key indicators” that can be linked to the specific patient behaviors and the environmental influences listed in Table 6 as being related to access to care. Changes in these indicators can be used to measure the success of programs. Other methods for identifying the health problems of a particular community or practice have been developed. Kozoll et a1.27, 38 have created a tool that can help practitioners work through the process of defining health problems and linking it with incidence or prevalence data appropriate for community or practice measurement. Procedures for evaluation of a private practice for health problems and for targetin at-risk individuals have also been described.‘5, 39 With increasing emphasis on individual and group accountability for medical practice, these

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TABLE 8. “Key indicators” that can be linked to the specific patient behaviors and the environmental influences listed in Table 5 as being related to access to care. These can be used to measure efficacy of the health promotion program.

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Child assumption of personal responsibility for health No. of adolescents who independently seek health supervision No. of sexually active adolescents who receive birth control from provider No. of adolescents who smoke

are practical instruments and approaches providers can use to convert theories into reality. Phase 3 in the PRECEDE-PROCEED model is the “behavioral and environmental assessment.” Simply stated, the behavioral diagnosis is a systematic analysis of patient behaviors that can be linked to the goals that were identified in the preceding stages, in this case access to care. Environmental diagnosis is identification of factors in the social and physical environment that are related to the behavior or to the outcome of interest. Table 6 lists the behavioral and environmental components of access to care that can be directly influenced during the health supervision visit. The rationale behind this assessment relates to the fact that the physician and the physician’s office are the “point of entry” into the health care system for 80% of children and their families.” The health care provider’s office or a clinic is the “point of entry” into the system for the child and his or her family. Every child needs a “medical home.” The process of preventive health care is continuing and longitudinal. Even though many other types of providers are integral to the health care system, the pediatrician or family physician should be the head of the health care team. Children deserve to have the most qualified person coordinate the services that they need. Among the factors listed in Table 6 are formation of ‘a therapeutic alliance, parental use of the provider as a resource to access beneficial services, and availability of providers. These concepts can be directly re-

lated to the question of who should be delivering preventive services. Nonphysician providers are playing an increasing part in providing primary care and health supervision services. 40, 41 Their participation in such activities should increase the availability of providers. However, the most effective role nonclinician providers can play is as yet unclear. Most advanced practice nurses and all physician assistants currently work collaboratively with physicians. The major issue that threatens this relationship is disagreement regarding the scope of nurse practitioners.42 Their training is both different and much less extensive than that of primary care physicians. Often the preparation of nonphysician providers is more oriented toward prevention. They may thus be better prepared to provide direct care, particularly related to health education and counseling. However, the overall planning for preventive services and the coordination of care is very complex. There have been no well-designed studies of nurse practitioners in independent practice. Until such studies demonstrate that nonphysician providers can be equally effective as primary care physicians in the coordination, planning, and delivery of prevention services, it is my opinion that the responsibility for these tasks should remain with primary care physicians who are well trained in the care of children. The key indicators found in Table 8 could be used to measure the impact of nonphysicians on access to care. The complexities of the tasks that must be performed to adequately provide primary and preventive health care have not been appreciated by the medical community. As is described in this monograph, logical consideration of a single visit, when put into the context of overall care, requires an extensive information base. The performance of such a visit involves knowledge not only of content but also of families, family structure, child development, and the community. Added to these necessities are extensive organizational and communication skills. The physician, with his or her broad perspective and extensive training, is the best person to either directly provide these services or to supervise and coordinate their delivery. The ideal relationship between physicians and nonphysician providers should be defined in a collaborative manner that ensures that each fulfills the roles for which there has been adequate training and expertise. The health supervision visit is an excellent vehicle for ensuring that children have access to the services they need. Because children cannot independently access care or manage their health, formation of a therapeutic alliance between the parent and the provider is essential. This can best be done

when parents are not stressed by an ill child and when there is adequate time to establish rapport. Regularly scheduled health supervision visits are important in the formation of the doctor-patient relationship and the attachment of the family to the primary care provider. During health supervision visits, the provider can also help families take responsibility for their health, can assist families when other types of services are necessary or would be beneficial, and, finally, as children mature, can teach them how to assume personal responsibility for health behaviors. Although these sound like lofty goals, they are often accomplished by primary care providers. The effectiveness of child health supervision in terms of providing access to coordinated care can be measured by examination of the key indicators listed in Table 8. For example, the strength of the therapeutic alliance can be measured by the number of patients who voluntarily change providers. In a comparative study of individual and group well-child care, a method of delivering care that is described below in which children and families are seen in groups, significantly more families who received individual care chose to change providers, citing dissatisfaction with the care received. Numbers of after-hours calls and visits and use of emergency services are also indicators of the provider’s accessibility and families’ confidence in the care rendered. The first three phases of the PRECEDEPROCEED model for planning a health promotion program identify sequentially the social, epidemiologic, behavioral, and environmental diagnoses that define the actions and conditions of living that affect the health of the population of interest. Phase four of PRECEDE identifies the “educational and organizational” factors that must be changed to initiate and to sustain behavioral and/or environmental change. Three categories of factors influence patient behavior: predisposing factors that are antecedents to behavior that are the motivation for that behavior; enabling factors that allow a motivation to be actualized; and reinforcing factors that occur subsequent to the behavior and provide the reward or incentive for persistent or continuous change. Table 7 lists some of the factors related to access to care. For the pediatrician to understand the predisposing factors that will influence formation of a therapeutic alliance, he or she must have excellent communication skills and an ability to astutely observe parental behaviors and the parent-child interaction. These factors are also key if the provider is to help families create a positive environment for their children. Effective patient education is extremely difficult to deliver in the traditional lo- to 15-minute visit.

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During this short interval, the provider must, in addition to gathering historical data and doing a physical examination, establish rapport, give reassurance, teach, and identify obstacles to behavior change.43 Group well-child care is a method of care that can obviate many of the obstacles to providing an ideal educational and organizational environment. In this model families are invited to attend educational sessions on the same schedule as recommended by the American Academy of Pediatrics. Infants receive the usual health screening and immunizations, but either before or after a brief physical examination, families are gathered in the waiting room for a l-hour discussion of child development, common behavioral issues, and other topics relevant to age-specific health promotion. Although group care is a method that probably does increase the quality of the physicianparent alliance, this has not been proven. Its efficacy in delivering health information and in helping to support families has been demonstrated. The role of group care in supporting families so that the child is in a nurturing environment will be described later. It is not until the next stage, phase 5, health promotion, that the actual intervention is planned and implemented. It is here that the programs described by the Bright Futures Panels and the American Academy of Pediatrics can be put into context. It should also be noted that it is not until phase 4 that the availability of health insurance is factored into the equation. Simple assurance of universal funding for care, although important, is only one of many factors that effects whether children receive the health care they need. Phase 5 marks the conclusion of the PRECEDE portion of the model. The PROCEED segment describes the evaluation of health promotion programs. If the PRECEDE section has been carefully conducted, the evaluation procedures will be obvious and most of the essential baseline information will already have been gathered. As Green and Kreuter’ point out: “A fully developed PRECEDE plan with social, health, behavioral, environmental, and educational objectives that are realistic, and with program activities and methods that are sound and targeted to those objectives, should lend itself easily to an evaluation that will detect the changes implicit in the objectives.” The first question that needs to be asked is what level of outcome is sufficient to indicate success: process, impact, or outcome evaluation? The indicators and methodologies for detecting differences are different for each level. Process evaluation refers to whether and how well the program and/or its segments have been implemented. This kind of evaluation, although intermediate, is extremely important

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and almost never done in studies of well-child care. The importance of one simple concept of epidemiology should indicate why process evaluation is key. The effect of any factor on the eventual outcome of patients can only be determined if the exposure and its extent is known. Whether and how much patients smoke is central to understanding lung cancer. How can one determine the efficacy of a prevention program if the extent to which the program was actually delivered is never measured. Only one study has examined the extent to which practicing pediatricians cover the recommended content of the Guidelines for Health Supervision. 44 In the example of access to care the factors elucidated in phase 4 (Table 7) are used in phase 7 for process evaluation. The next level of evaluation is impact evaluation. This measures the immediate effect of the program on targeted behaviors and environmental factors and their antecedent predisposing, enabling, and reinforcing factors. The key indicators listed in Table 8 could be used in an impact evaluation. Finally, the third level of evaluation is measurement of outcomes. The objectives for health status and quality of life crafted in the earliest stages of the planning process provide the basis for measuring the overall success ‘of the program. If, indeed, child health supervision leads to improved access to care and more appropriate use of services, these measures supply a method for creating a cost-benefit analysis and defining potential or real savings. By defining reasonable, attainable outcomes for well-child care and devising practical health promotion interventions it should be possible to answer the question: Is child health supervision effective?

Application of the PRECEDE-PROCEED Model for Providing Family Support Every study of the long-term well-being of children has indicated that a supportive family environment is the key factor.“, 22 Can clinicians affect the quality of children’s family lives through child health supervision visits? Even with the above explanations of the PRECEDE-PROCEED model, it is unlikely that those unfamiliar with this kind of health promotion planning will comfortably follow the various steps. For ease of reading and understanding, the phases (steps) are briefly described again. Phase 1 of the model, the social diagnosis, would define the ultimate outcome as family environments that can adequately meet the physical, emotional, and psychologic needs of children. The desired child outcome is development into physically, emotionally, and mentally healthy adults. Phase 2 describes epidemiologically the problems

that can threaten ideal outcomes. Obviously, in the case of providing for a supportive family environment, these issues are complex, requiring that the home be a stable, safe, place where a child feels physically and emotionally secure. Important factors include who is in the home, the characteristics of family members, the relationships of family members to each other and to the child, and the physical environment. Problems shown to negatively affect child outcomes include family dysfunction (including poor marital relationships and family violence), parental alcoholism or drug abuse, parental psychiatric illness, parental criminality, and parental education.45-48Because of the complexity of even this single outcome goal, one factor related to parental mental health, depression, will be discussed as the targeted health problem. This health problem meets the requirements of phase2 of PRECEDE: the problem is significant, common, and threatens the stated desired outcomes described in phase1. Data to support this supposition are outlined below. Parental depression has repeatedly been shown to be detrimental to children’s mental and physical health.49, 5o The children of parents with affective mood disorders are at increased risk for poor functioning, including learning, behavioral, and psychiatric problems. As teenagers, they are prone to psychosomatic complaints, and as adults, they are more likely than children of mentally healthy parents to eventually have mood disorders develop. Epidemiologic data also indicate that parental mood disorders are exceedingly common, with estimates of the prevalence of diagnosable major depression among women ranging from 4% to 9%.51, 52 Many more suffer with depressive symptoms.53, 54 Phase three in the PRECEDE-PROCEED model is the assessment of the behaviors that can be linked to creating an optimal family environment and of the related factors in the social and physical environment. Effective child-rearing takes energy and attention. Depression has been shown to be more disabling than any other chronic illness.55 Certainly, the quality of parent-child interaction and parenting skills are behaviors that contribute to a supportive family environment. Both of these factors have been shown to be adversely affected by parental depression 56, 57 Phasefour of PRECEDE identifies the predisposing, enabling, and reinforcing factors that affect the health behaviors and environmental influences described in phase3. In this example of parental depression the factors that would be significant are those that would predispose parents to the illness, that would affect their ability to seek and receive treatment or preventive interventions (enabling), and that

TABLE 9. PRECEDE-PROCEED phases for provision supportive family environment through child health supervision using parental mental health as target behavior Quality

of life

Epidemiologic diagnosis

Behavioral diagnosis

Environmental diagnosis

Educational diagnosis Predisposing factors

Enabling

factors

Reinforcing factors Preventive intervention

Process evaluation

Impact evaluation

Outcome evaluation Intermediate Long-term

Current

of a

Supportive home environment that provides for child’s physical, mental, and emotional needs Family dysfunction, parental alcoholism or drug abuse, parental psychiatric illness, parental criminality, and parental education Parenting skills, parent-child interactions, child abuse/neglect, parental drug/alcohol abuse, use of health care system, parental employment Parental age, support system, poverty, family dysfunction, low maternal education, immigrant status, community environment Family history mood disorder, attitudes toward treatment, perceived need for treatment, parental knowledge of treatment and beliefs regarding possible efficacy Positive parental attitudes regarding treatment, parental compliance with treatment regimens, availability of and access to treatment programs, availability of prevention programs, strong, therapeutic alliance with health provider Supportive environment, positive response to treatment Psychosocial screening, group child health supervision, individual counseling, referral for treatment, long-term follow-up No. screened for psychosocial risk factors, no. with positive screen followed and diagnosed, no. with diagnosis treated or referred, no. attending group care Use of health care services, no. referrals for child abuse/neglect, no. parents with active alcohol/drug abuse problems, no. parents with mental health problem, parental days missed work Children’s school performance, physical health Incidence of mood disorders in children of affected parents, job functioning

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would encourage them to maintain their efforts (reinforcing). These are listed in Table 9. Phasefive is the planning and implementation of intervention programs. These can be related to either primary or secondary prevention. In this example primary prevention programs would attempt to prevent the development of depression or depressive symptoms before they occur. Secondary programs would involve screening for parental depression, further evaluation of those with positive screening, and treatment for those who are diagnosed with the disease. All of these activities are possible in a child health supervision visit. The preventive activities of a wellchild visit have been described above as screening,diseaseprevention and health promotion, and patient managementand follow-up. Screening for parental depression meets all the requirements for screening. Several reliable, valid screening instruments are available and have been used in pediatric settings.i9, 35The condition is common, effective interventions are available for those who have the disease, and treatments have been shown to be cost-effective.58-60 Clinicians can use screeners to select the population of parents who are likely to be suffering from significant depression and, with little extra training, can learn to ask appropriate questions to make the diagnosis with reasonable certainty. They can then refer families for treatment. However, if the pediatrician’s reason for screening, diagnosing, and referring families is to ensure an adequate home environment for the child, his or her role must be a continuing one. Although the parent’s therapist will treat the depression, it is the pediatrician who can assessthe parent-child interaction problems and help the family with parenting skills. Primary prevention is also possible in a child health supervision visit. Counseling has been shown to be helpful, not just in the treatment of depression but also in its prevention. Postnatal depression appears to be particularly amenable to such interventions. Therapeutic listening and simple nondirective counseling have been demonstrated to be a tremendous help to parents attempting to cope with their constantly changing roles. Early, preventive interventions, including counseling regarding infant behavior and characteristics and family organization and functioning, have been demonstrated to positively affect parent-child interactions among premature infants and improved mothers’ sense of wellbeing.61 Although intensive intervention is not possible in a short, individual, child health-supervision visit, group care, as described above, has been demonstrated to accomplish many of these goals. In a controlled study parent groups in pregnancy and the

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perinatal period have been demonstrated to decrease the number of depressive symptoms among women in the postnatal period.62 One key aspect of group care that cannot be accomplished in an individual visit is group support. Children live with families, not alone. The structure of a group forces its members to interact, allowing the provider to observe how the families respond. Their interactions with each other, with other group members, and their child bring out psychologic issues that would not otherwise be apparent. 63 One of the central issues related to building a support system is the tension between “engulfment versus estrangement.” Engulfment refers to the desire to join, to merge, to commit, to become one with, to lose one’s independent identity. This is reflected in the drive to form relationships. In psychologic terms engulfment implies loss of individuation. The second tendency is to separate, to become unique, to be apart from, to be an individual. This is individuation or estrangement. These two tendencies present a constant conflict because they are in opposition: you cannot have it both ways. Many families have a great deal of difficulty resolving these issues both for themselves and for their children. Group well-child care offers the provider the opportunity to help facilitate group exchange and interaction. If the groups of parents meet repeatedly over time, social support grows among the group members for their parenting roles. In fact, comparative studies of traditional and group well-child care have shown that group care is more likely to positively affect some of the key indicators outlined in Table 8.64 Compared with families attending traditional, individual visits, twice as many parents (92% of the experimental group) attending group care reported that they received significant support during well-child encounters. The last three phases of the PRECEDE-PROCEED model are the program evaluation component. As outcomes for preventive interventions are increasingly stressed, this aspect of any prevention program will be essential. Table 9 lists measures that could be used in process, impact, and outcome evaluation. Application of the PRECEDE-PROCEED Model to Physical Health and Safety The other two domains that can be positively influenced during a child health supervision visit are those of physical health and safety. Table 10 lists the factors for each of the phases of PRECEDE and key indicators for PROCEED that could be used for process, impact, and outcome evaluation. Physical fitness and cardiovascular health are used as examples of how this process can be used to determine the im-

portant health outcomes, the factors that influence health, and the related health behaviors. Activities that can be implemented during an office visit include historical screening for risk factors related to cardiovascular disease, case-finding of children with hypercholesterolemias, dietary counseling and referral for those who are deemed to be at higher risk or desire more detailed education, and follow-up and management of patients who need treatment.10-12 Programs for encouraging families to participate in fitness activities have also been designed.r2 The efficacy of each component of the office-based prevention strategies can be tested for specific objectives using the key indicators listed in Table 10. Using this process, the efficacy of intervention strategies can be examined in a different way. Provision of physical safety is an excellent example that demonstrates that, indeed, child health supervision visits can be effective. Table 11 lists the components of a program to promote physical safety. Process evaluation has demonstrated that counseling regarding safety issues is more consistently given during group well-child care visits.44 Impact evaluation studies have shown that we&child care increases the use of smoke alarms and has influenced to change the settings on hot water heaters. iFnts Counseling and distribution of discount coupons during child health supervision visits were among the methods used in the Seattle Children’s Bicycle Helmet Campaign. 66 Impact evaluation confirmed that, through a combination of interventions, this campaign increased use of helmets from 5.5% in 1987 to almost 60% in the fall of 1993.16 Outcome evaluation demonstrated a dramatic, significant decline in medically treated head injuries from bicycle accidents, with injuries decreasing by 66% in a surveillance population.

Ending with the Beginning The evidence on the effectiveness of components care . . is more remarkable for its limitations jindings. Office of Technology

of well-child than for its

Assessment, February 1988.3

Although many have contended that preventive health care for children has not been demonstrated to be effective, there is increasing evidence that with well-designed programs, improved outcomes are indeed possible. Asking the question, “Is well-child care effective?” is somewhat like asking, “Does the health care system work?” The wise use of preventive interventions is a very complex, complicated matter that requires consideration not only of health care but also of the context in which the care is given.

TABLE 10. PRECEDE-PROCEED model for promotion physical health through child health supervision Key indicators

Phases Quality

of

of life

Epidemiologic diagnosis Behavioral diagnosis Environmental diagnosis Educational diagnosis Predisposing factors Enabling factors

Reinforcing factors Intervention

Process evaluation

Impact evaluation

Outcome evaluation Intermediate

Long-term

Cardiovascular disease, reduction in cardiovascular morbidity and mortality, improved fitness, better school performance Lower blood pressure, lower LDL cholesterol, higher HDL cholesterol, lower body fat Eating behaviors, exercise behaviors Supportive family and school environment Biologic lipid disorders, child and parental knowledge, attitudes, and skills (e.g., self-control) Accessibility of screening, education programs, physical education and sports programs, availability of nutritional school lunch programs Attitudes and behaviors of family, peers, teachers, parents’ limit-setting abilities, parents’ role-modeling behaviors Child health supervision, screening by history, diet counseling and referral when necessary, physical fitness counseling, medical treatment Appropriate screening, adequate counseling and referral done, physical fitness counseling done, appropriate medical treatment No. children who exercise regularly, no. with appropriate caloric intake, no. with appropriately balanced diet, no. children meeting current recommendations for pattern of intake for saturated fats, total fat, and dietary cholesterol No. children normal’weight, no. children with normal cholesterol, no. meeting physical fitness criteria No. with high blood pressure, no. with premature cardiac disease, no. with cerebrovascular accidents

Personal care (such as child health supervision) is only one method for delivering preventive interventions; however, it is an essentialand integral part of any program that attempts to improve the quality of children’s lives. Some of the desired outcomes discussed in this monograph can only be attained

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TABLE 11. PRECEDE-PROCEED model for promotion of physical safety through child health supervision Phases

Key indicators

Quality of life

Epidemiologic diagnosis Behavioral diagnosis Environmental diagnosis

Educational diagnosis Predisposing factors Enabling factors

Reinforcing factors Intervention

Process evaluation Impact evaluation

Outcome evaluation Intermediate

Long-term

Children who grow to adulthood without suffering the consequences of accidental and nonaccidental trauma Physical and sexual abuse, home accidents, automobile/ pedestrian/bicycle injuries, poor physical fitness Parent’s impulse control and parenting skills, seat belt use, bicycle helmet use Supportive family environment, availability of home visiting programs, effective protective services, safety-proofed home, presence of smoke alarms in home, hot water heater set <120” C, bicycle paths Child and parental knowledge, attitudes, and skills regarding safety Accessibility of education programs, availability of inexpensive bicycle helmets, helmet and seat belt laws, enforcement of safety laws Attitudes and behaviors of family, peers, teachers, role-modeling behaviors Screening by history for risk factors for physical and sexual abuse, counseling and referral when necessary, counseling regarding safety-proofing home, use of seat belts and car seats, use of bicycle helmets Appropriate screening, adequate counseling and referral done No. child/sexual abuse referrals, no. households with smoke alarms, no. households with hot water heater <120” C, no. children in car seats, using seat belts, ‘using bicycle helmets No. children with medically treated head injuries, no. children injured in automobile accidents Decrease in no. of accidental deaths, decrease in no. of physically and sexually abused children

through the provider-patient relationship, whereas others need a broader involvement of the community and the political system. Concern regarding health care expenditures has

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increased interest in prevention. Yet, unless programs are well conceived, efficiently implemented, and effectively researched, 10 years hence a follow-up report from the Office of Technology Assessment may reach the same conclusions as in 1988. For prevention to be cost-effective careful study and rational implementation of programs is essential.67 The number of issues that must be addressed is vast. Among the questions that need to be researched are the cost-effectiveness of interventions, the periodicity of care, methods of intervention, who should provide the direct care, and the effects of managed care on the delivery of preventive services. The framework developed by Green and Kreuter provides a process for conceptualizing and researching health promotion and disease prevention that can lead to rational development and implementation of effective programs. If this is accomplished, perhaps the next Task Force on Prevention will write: The Task Force notes that the value ofpreventive child health care has been documented with scient@c evidence; it has been quantljied, justified and documented to be coste@ctive. Task Force on the Effectiveness of Preventive Child Health Care, the American Academy of Pediatrics, June 2004.

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