Evaluation of integrated community case management of the common childhood illness program in Gondar city, northwest Ethiopia: a case study evaluation design.

BACKGROUND: Integrated Community Case Management (ICCM) of common childhood illness is one of the global initiatives to reduce mortality among under-five children by two-thirds. It is also implemented in Ethiopia to improve community access and coverage of health services. However, as per our best knowledge the implementation status of integrated community case management in the study area is not well evaluated. Therefore, this study aimed to evaluate the implementation status of the integrated community case management program in Gondar City, Northwest Ethiopia. METHODS: A single case study design with mixed methods was employed to evaluate the process of integrated community case management for common childhood illness in Gondar town from March 17 to April 17, 2022. The availability, compliance, and acceptability dimensions of the program implementation were evaluated using 49 indicators. In this evaluation, 484 mothers or caregivers participated in exit interviews; 230 records were reviewed, 21 key informants were interviewed; and 42 observations were included. To identify the predictor variables associated with acceptability, we used a multivariable logistic regression analysis. Statistically significant variables were identified based on the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p-value. The qualitative data was recorded, transcribed, and translated into English, and thematic analysis was carried out. RESULTS: The overall implementation of integrated community case management was 81.5%, of which availability (84.2%), compliance (83.1%), and acceptability (75.3%) contributed. Some drugs and medical equipment, like Cotrimoxazole, vitamin K, a timer, and a resuscitation bag, were stocked out. Health care providers complained that lack of refreshment training and continuous supportive supervision was the common challenges that led to a skill gap for effective program delivery. Educational status (primary AOR = 0.27, 95% CI:0.11-0.52), secondary AOR = 0.16, 95% CI:0.07-0.39), and college and above AOR = 0.08, 95% CI:0.07-0.39), prescribed drug availability (AOR = 2.17, 95% CI:1.14-4.10), travel time to the to the ICCM site (AOR = 3.8, 95% CI:1.99-7.35), and waiting time (AOR = 2.80, 95% CI:1.16-6.79) were factors associated with the acceptability of the program by caregivers. CONCLUSION AND RECOMMENDATION: The overall implementation status of the integrated community case management program was judged as good. However, there were gaps observed in the assessment, classification, and treatment of diseases. Educational status, availability of the prescribed drugs, waiting time and travel time to integrated community case management sites were factors associated with the program acceptability. Continuous supportive supervision for health facilities, refreshment training for HEW's to maximize compliance, construction clean water sources for HPs, and conducting longitudinal studies for the future are the forwarded recommendation.

Proposed framework and knowledge synthesis of services delivered by specialized professionals in childcare settings: A scoping review.

BACKGROUND: Services from specialized professionals in childcare settings contribute to support early childhood development. Little is known, however, about how services are delivered in this context. The aims of this scoping review were to propose a framework to describe services delivered by specialized professionals in childcare contexts and synthesize knowledge about those services. METHODS: Documents published between 2000 and 2022 in APA PsychINFO, ERIC, CINAHL and MEDLINE were included. These documents described services delivered by a range of specialized professionals (e.g., speech-language pathologists, occupational therapists, physical therapists and early childhood special education teachers) in childcare contexts and whose aim was to support motor, cognitive, affective, language or social development of children. Deductive and inductive qualitative analyses and descriptive statistics were carried out. RESULTS: The review included 47 documents. The Description of Services delivered by specialized Professionals in Early Childhood (D-SPEC) Framework emerged from qualitative analyses. The D-SPEC Framework included 11 dimensions: three actors and their context, specialized professionals involved, children served, purpose of service, type of service, service duration and intensity, mode of service delivery, mode of access to services and funding. Most services delivered by specialized professionals in childcare were provided by a single professional and targeted language. Two documents described multitiered service delivery models with a continuum of services ranging from general support for all children to individualized interventions for children with specific needs. In-context services were preferred to pull-out services in most documents reviewed. CONCLUSIONS: The D-SPEC Framework may be a useful tool to assist researchers in documenting and comparing services delivered by specialized professionals. More importantly, this framework will facilitate the development of intersectoral and interdisciplinary services essential for supporting early childhood development. Multitiered service delivery models appeared to be a promising way to develop those services addressing the various needs encountered in childcare.

Service design for children and young people with common mental health problems: literature review, service mapping and collective case study.

Background: The mental health of children/young people is a growing concern internationally. Numerous reports and reviews have consistently described United Kingdom children's mental health services as fragmented, variable, inaccessible and lacking an evidence base. Little is known about the effectiveness of, and implementation complexities associated with, service models for children/young people experiencing 'common' mental health problems like anxiety, depression, attention deficit hyperactivity disorder and self-harm. Aim: To develop a model for high-quality service design for children/young people experiencing common mental health problems by identifying available services, barriers and enablers to access, and the effectiveness, cost effectiveness and acceptability of such services. Design: Evidence syntheses with primary research, using a sequential, mixed-methods design. Inter-related scoping and integrative reviews were conducted alongside a map of relevant services across England and Wales, followed by a collective case study of English and Welsh services. Setting: Global (systematic reviews); England and Wales (service map; case study). Data sources: Literature reviews: relevant bibliographic databases and grey literature. Service map: online survey and offline desk research. Case study: 108 participants (41 children/young people, 26 parents, 41 staff) across nine case study sites. Methods: A single literature search informed both reviews. The service map was obtained from an online survey and internet searches. Case study sites were sampled from the service map; because of coronavirus disease 2019, case study data were collected remotely. 'Young co-researchers' assisted with case study data collection. The integrative review and case study data were synthesised using the 'weaving' approach of 'integration through narrative'. Results: A service model typology was derived from the scoping review. The integrative review found effectiveness evidence for collaborative care, outreach approaches, brief intervention services and the 'availability, responsiveness and continuity' framework. There was cost-effectiveness evidence only for collaborative care. No service model appeared to be more acceptable than others. The service map identified 154 English and Welsh services. Three themes emerged from the case study data: 'pathways to support'; 'service engagement'; and 'learning and understanding'. The integrative review and case study data were synthesised into a coproduced model of high-quality service provision for children/young people experiencing common mental health problems. Limitations: Defining 'service model' was a challenge. Some service initiatives were too new to have filtered through into the literature or service map. Coronavirus disease 2019 brought about a surge in remote/digital services which were under-represented in the literature. A dearth of relevant studies meant few cost-effectiveness conclusions could be drawn. Conclusions: There was no strong evidence to suggest any existing service model was better than another. Instead, we developed a coproduced, evidence-based model that incorporates the fundamental components necessary for high-quality children's mental health services and which has utility for policy, practice and research. Future work: Future work should focus on: the potential of our model to assist in designing, delivering and auditing children's mental health services; reasons for non-engagement in services; the cost effectiveness of different approaches in children's mental health; the advantages/disadvantages of digital/remote platforms in delivering services; understanding how and what the statutory sector might learn from the non-statutory sector regarding choice, personalisation and flexibility. Study registration: This study is registered as PROSPERO CRD42018106219. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/09/08) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 13. See the NIHR Funding and Awards website for further award information.

In this research study, we explored services for children and young people with 'common' mental health problems like depression, anxiety and self-harm. We aimed to find out what services exist, how children/young people and families find out about and access these services, what the services actually do, whether they are helpful and whether they offer value for money. We looked at the international literature (reports and research papers) to identify different approaches to providing support, and to find out whether certain approaches worked better than others and whether children/young people and families preferred some approaches over others. The literature provided very little information about the value for money of services. We also carried out a survey and used the internet to identify 154 relevant services in England and Wales. To explore services in more detail, and hear directly from those using them, we planned to visit 9 of the 154 services to interview children/young people, parents and staff. Unfortunately, coronavirus disease 2019 stopped us directly visiting the nine services and so we conducted phone and video interviews instead. We still managed to speak to, and hear the experiences of, more than 100 people (including children/young people and parents). We combined information from the literature with information from the interviews to create an evidence-based 'model' of what services should look like. This model considers some basic things like how quickly children/young people could access a service, what information was available, the importance of confidentiality and whether staff make the service fit with the child/young person's needs and interests. It also considers whether the service helps children/young people learn skills to manage their mental health and whether staff at a service work well together. We hope our model will help existing and new services improve what they offer to children/young people and families.

An innovative and collaborative method to develop a model care and service trajectory for the assessment, diagnosis, and support of children with developmental disabilities.

This paper documents an innovative research approach undertaken to co-develop an integrated assessment, diagnosis, and support service trajectory for children suspected of having a developmental disability. It employed data-driven practices and involved multiple stakeholders such as parents, professionals, managers, and researchers. It emphasized the importance of incorporating experiential knowledge adopting an integrated care and service trajectory perspective, and using an implementation science framework. The first part of this article presents the theoretical roots and the collaborative method used to co-construct the model trajectory. The second part of this article presents the results of a survey in which participating stakeholders shared their point of view on the value and impact of this approach Overall, this article provides a step-by-step operationalization of participative research in the context of public health and social services. This may help guide future initiatives to improve services for developmental disabilities in partnership with those directly concerned by these services.

Linking communities and health facilities to improve child health in low-resource settings: a systematic review.

Community-facility linkage interventions are gaining popularity as a way to improve community health in low-income settings. Their aim is to create/strengthen a relationship between community members and local healthcare providers. Representatives from both groups can address health issues together, overcome trust problems, potentially leading to participants' empowerment to be responsible for their own health. This can be achieved via different approaches. We conducted a systematic literature review to explore how this type of intervention has been implemented in rural and low or lower-middle-income countries, its various features and how/if it has helped to improve child health in these settings. Publications from three electronic databases (Web of Science, PubMed and Embase) up to 03 February 2022 were screened, with 14 papers meeting the inclusion criteria (rural setting in low/lower-middle-income countries, presence of a community-facility linkage component, outcomes of interest related to under-5 children's health, peer-reviewed articles containing original data written in English). We used Rosato's integrated conceptual framework for community participation to assess the transformative and community-empowering capacities of the interventions, and realist principles to synthesize the outcomes. The results of this analysis highlight which conditions can lead to the success of this type of intervention: active inclusion of hard-to-reach groups, involvement of community members in implementation's decisions, activities tailored to the actual needs of interventions' contexts and usage of mixed methods for a comprehensive evaluation. These lessons informed the design of a community-facility linkage intervention and offer a framework to inform the development of monitoring and evaluation plans for future implementations.

Immigrant Mothers' Perspectives on Pediatric Primary Care: Challenges and Solutions to Improve Medical Home Use.

Children in immigrant families (CIF) constitute 25% of all children in the United States. Known barriers to accessing and navigating the health care system for immigrants (i.e., poverty, fear, limited English proficiency, lack of insurance) lead to decreased medical home establishment among CIF, although the ways in which these obstacles affect medical home access are less studied. With a focus on Congolese, Afghan, Syrian/Iraqi, and Central American immigrants, key informant interviews and focus groups were conducted to identify mothers' perceptions of and experiences with pediatric primary health care. Five common themes emerged: mothers' critical role in children's health, uniqueness of the U.S. health care system, logistical challenges, influence of prior clinical experiences, and importance of culturally appropriate communication. Few, but distinct, differences among the groups revealed specific obstacles for individual populations. Improving rates of medical home use among CIF requires targeted, immigrant-informed approaches that involve population outreach as well as systems-level changes.

Improving access to child abuse evaluations through innovation & telemedicine.

Many children and families do not have access to specialized pediatric health care, including child abuse pediatricians. Medical evaluations in cases of suspected child maltreatment including physical abuse, sexual abuse, and neglect are a critical component of the multidisciplinary team response to these concerns. We review the role of child abuse pediatricians in cases of suspected child maltreatment. We discuss the advantages and disadvantages of current models of care including co-location of child abuse specialists within children's advocacy centers, hospital-based medical evaluation programs and community-based clinics. We review barriers to universal and equitable access to specialized care. We then highlight the significance of telemedicine as an important tool for improving access to care for children who would not otherwise have access.

Pediatric Mental Health Care and Scope-of-Practice Expansions.

To examine the association between psychologist and nurse practitioner scope-of-practice (SoP) regulations and pediatric mental health service access. A nationally representative sample of children with mental health needs was identified using 5 years of National Survey of Children's Health (2016-2020). Utilization was measured in two ways: (1) unmet mental health care needs and (2) receipt of mental health medication. Expanded SoP for psychologists and nurse practitioners was measured based on the child's state of residence and the year of the survey. The associations between both SoP expansion and both outcomes were assessed using logistic regression models adjusted for multiple covariates. The probability of having unmet mental health needs was 5.4 percentage points lower (95% CI - 0.102, - 0.006) for children living in a state with psychologist SoP expansion; however, there was no significant difference in unmet mental health needs between states with and without NP SoP expansion. The probability of receiving a mental health medication was 2.0 percentage points higher (95% CI 0.007, 0.034) for children living in a state with psychologist SoP expansion. Conversely, the probability of receiving a mental health medication was 1.5 percentage points lower (95% CI - 0.023, - 0.007) for children living in a state with NP SoP expansion. Expanded SoP for psychologists is associated with improved access to pediatric mental health care in terms of both unmet need and receiving medication. Expanded SoP for NPs, however, was not associated with unmet need and lower receipt of medication.

Using Quality Improvement as a Mechanism for Fostering Partnerships and Promoting Equity in a Health System Change Model.

PURPOSE: Quality improvement (QI) processes provide a framework for systematically examining target outcomes and what changes can be made to result in improvement and ensure equity. We present a case study of how QI processes were used as a means of partnership building to enhance equity in designing materials for a Medicaid pilot program, North Carolina Integrated Care for Kids (NC InCK). DESCRIPTION: The NC InCK model addresses social determinants of health by providing structured care integration across core child health and social service areas and using an alternative payment model to incentivize high quality child outcomes. During the two-year planning period prior to the NC InCK model launch, we used Plan-Do-Study-Act (PDSA) cycles to conduct usability testing as a QI strategy for a component of the NC InCK model: the Shared Action Plan (SAP). ASSESSMENT: We conducted usability testing with four Family Council members, nine care managers, and one physician. Participants reviewed the SAP and provided feedback via a survey. After reviewing feedback with InCK leadership and the Family Council, we implemented recommendations that led to a SAP that uses clear and accessible language, that highlights family strengths and family-identified goals, and that is distinct from other care management plans. CONCLUSION: Usability testing forced refinement of materials before NC InCK launched, created opportunities for building and enhancing community partnerships and promoted equity within the NC InCK team and Family Council by considering multiple perspectives when deciding on SAP revisions.

Innovative Programs with Multi-Service Integration for Children and Youth with High Functional Health Needs.

The integration of care services and providers across the health-social-community continuum has helped improve the lives of many children and youth living with complex health conditions. Using environmental scan data, 16 promising multi-service programs were selected and analyzed qualitatively through a deliberative conversation approach. Descriptive data of analyzed programs are presented, as well as the thematic analysis results. An important program strength is its clear founding principles and engagement of patients and families. However, the scale-up of these initiatives remains a challenge unless such programs can be better financed and supported.

Examining the Implementation of Health-Related Social Need (HRSN) Screenings at a Pediatric Community Health Center.

INTRODUCTION: Social determinants of health (SDoH) influence health outcomes and screening for health-related social needs (HRSN) is a recommended pediatric practice. In 2018, Denver Health and Hospitals (DH) implemented the Accountable Health Communities (AHC) model under the Centers for Medicare and Medicaid Services (CMS) and began using the AHC HRSN screening tool during selected well child visits (WCVs) at a DH Federally Qualified Health Center (FQHC). The current evaluation aimed to examine the program implementation and identify key lessons learned to inform the expansion of HRSN screening and referral to other populations and health systems. METHODS: Patients who completed a WCV between June 1, 2020 and December 31, 2021 (N = 13 750) were evaluated. Frequencies and proportions were used to describe patient characteristics of those that had a WCV, were screened, and received resource information. Multivariable logistic regression models with odds ratios (OR) and 95% confidence intervals (CI) were used to determine the association between patient characteristics and completing HRSN screening and provision of resource information. RESULTS: The screening tool was completed by 80% (n = 11 004) of caregivers bringing children to a WCV at the DH Westside Clinic, with over one-third (34.8%; n = 3830) reporting >1 social need. Food insecurity was the most common concern (22.3%; n = 2458). Non-English, non-Spanish (NENS) speakers were less likely to be screened (OR 0.43, 95% CI 0.33, 0.57) and less likely to report a social need (OR 0.59, 95% CI 0.42, 0.82) than speakers of English, after adjusting for age, race/ethnicity, and health insurance. CONCLUSIONS: A high rate of screening indicates feasibility of administering HRSN screenings for pediatric patients in a busy FQHC. More than a third of patients reported one or more social needs, underscoring the importance to identity these needs and the opportunity to offer personalized resources. Comparatively lower rates of screening and potential underreporting among NENS may be indicative of the availability and acceptability of current translation procedures as well as how the tool translates linguistically and culturally. Our experience highlights the need to partner with community organizations and involve patients and families to ensure SDoH screening and care navigation is part of culturally-appropriate patient-centered care.

Child and adolescent mental health services in a devolved healthcare system: a qualitative exploration of sustainable practices.

BACKGROUND: The transference of research evidence into routine healthcare practice remains poorly understood. This includes understanding the prerequisites of longer-term viability. The present study investigated the sustainable practices of GM i-THRIVE, a programme which reconceptualizes mental health services for children and young people (CYP) in Greater Manchester, United Kingdom. We aimed to establish whether a sustainable future was likely, and to identify areas of focus to improve that likelihood. METHODS: The NHS Sustainability Model, typically completed as a questionnaire measure, was converted into interview questions. The responses of nine professionals, from a variety of roles across the CYP mental health workforce, were explored using inductive thematic framework analysis. Selected participants completed the original questionnaire. RESULTS: Five themes (communication; support; barriers to implementation; past, present, and future: the implementation journey; and the nuances of GM i-THRIVE) and 21 subthemes formed the final thematic framework. Relationships with senior leaders and with colleagues across the workforce were seen as important. Leaders' roles in providing meaning and fit were emphasized. Whilst training delivered the programme's aims well, monitoring its dissemination was challenging. Widespread issues with dedicating sufficient time to implementation were raised. The flexibility of the programme, which can be applied in multiple ways, was discussed positively. This flexibility links to the idea of GM i-THRIVE as a mindset change, and the uniqueness of this style of intervention was discussed. To varying degrees, themes were supported by responses to the quantitative measure, although several limitations to the use of the questionnaire were discovered. Consequently, they were used to infer conclusions to a lesser degree than originally intended. CONCLUSIONS: Professionals involved with GM i-THRIVE reported many elements that indicate a positive future for the programme. However, they suggested that more attention should be given to embedding the core concepts of the model at the current stage of implementation. Limitations relating to its use within our study are discussed, but we conclude that the NHS Sustainability Model is a suitable way of guiding qualitative implementation research. It is especially valuable for localized interventions. The constraints of our small sample size on transferability are considered.

Contributions of Key Components of a Medical Home on Child Health Outcomes.

OBJECTIVES: The medical home model is a widely accepted model of team-based primary care. We examined five components of the medical home model in order to better understand their unique contributions to child health outcomes. METHODS: We analyzed data from the 2016-2017 National Survey of Children's Health (NSCH) to assess five key medical home components - usual source of care, personal doctor/nurse, family-centered care, referral access, and coordinated care - and their associations with child outcomes. Health outcomes included emergency department (ED) visits, unmet health care needs, preventive medical visits, preventive dental visits, health status, and oral health status. We used multivariate regression controlling for child characteristics including age, sex, primary household language, race/ethnicity, income, parental education, health insurance coverage, and special healthcare needs. RESULTS: Children who were not white, living in non-English households, with less family income or education, or who were uninsured had lower rates of access to a medical home and its components. A medical home was associated with beneficial child outcomes for all six of the outcomes and the family-centered care component was associated with better results in five outcomes. ED visits were less likely for children who received care coordination (aOR 0.81, CI 0.70-0.94). CONCLUSIONS FOR PRACTICE: Our study highlights the role of key components of the medical home and the importance of access to family-centered health care that provides needed coordination for children. Health care reforms should consider disparities in access to a medical home and specific components and the contributions of each component to provide quality primary care for all children.

Impact of COVID-19 Pandemic on Developmental Service Delivery in Children With a History of Neonatal Seizures.

BACKGROUND: Children with a history of acute provoked neonatal seizures are at high risk for disability, often requiring developmental services. The coronavirus disease 2019 (COVID-19) pandemic has led to widespread changes in how health care is delivered. Our objective was to determine the magnitude of service interruption of among children born between October 2014 and December 2017 and enrolled in the Neonatal Seizure Registry (NSR), a nine-center collaborative of pediatric centers in the United States. METHODS: This is a prospective cohort study of children with acute provoked seizures with onset ≤44 weeks' gestation and evaluated at age three to six years. Parents of children enrolled in the NSR completed a survey about their child's access to developmental services between June 2020 and April 2021. RESULTS: Among 144 children enrolled, 72 children (50%) were receiving developmental services at the time of assessment. Children receiving services were more likely to be male, born preterm, and have seizure etiology of infection or ischemic stroke. Of these children, 64 (89%) experienced a disruption in developmental services due to the pandemic, with the majority of families (n = 47, 73%) reporting that in-person services were no longer available. CONCLUSIONS: Half of children with acute provoked neonatal seizures were receiving developmental services at ages three to six years. The COVID-19 pandemic has led to widespread changes in delivery of developmental services. Disruptions in services have the potential to impact long-term outcomes for children who rely on specialized care programs to optimize mobility and learning.

Resolving Pediatric Preventive Care Gaps Through Hospital Inreach.

OBJECTIVES: Panel management processes have been used to help improve population-level care and outreach to patients outside the health care system. Opportunities to resolve gaps in preventive care are often missed when patients present outside of primary care settings but still within the larger health care system. We hypothesized that we could design a process of "inreach" capable of resolving care gaps traditionally addressed solely in primary care settings. Our aim was to identify and resolve gaps in vaccinations and screening for lead exposure for children within our primary care registry aged 2 to 66 months who were admitted to the hospital. We sought to increase care gaps closed from 12% to 50%. METHODS: We formed a multidisciplinary team composed of primary care and hospital medicine physicians, nursing leadership, and quality improvement experts within the Division of General and Community Pediatrics. The team identified a smart aim, mapped the process, predicted failure modes, and developed a key driver diagram. We identified, tested, and implemented multiple interventions related to role assignment, identification of admitted patients with care gaps, and communication with the inpatient teams. RESULTS: After increasing the reliability of our process to identify and contact the hospital medicine team caring for patients who needed action to 88%, we observed an increase in the preventive care gaps closed from 12% to 41%. CONCLUSIONS: A process to help improve preventive care for children can be successfully implemented by using quality improvement methodologies outside of the traditional domains of primary care.

Association of the COVID-19 Pandemic With Routine Childhood Vaccination Rates and Proportion Up to Date With Vaccinations Across 8 US Health Systems in the Vaccine Safety Datalink.

Importance: The COVID-19 pandemic has affected routine vaccine delivery in the US and globally. The magnitude of these disruptions and their association with childhood vaccination coverage are unclear. Objectives: To compare trends in pediatric vaccination before and during the pandemic and to evaluate the proportion of children up to date (UTD) with vaccinations by age, race, and ethnicity. Design, Setting, and Participants: This surveillance study used a prepandemic-postpandemic control design with data from 8 health systems in California, Oregon, Washington, Colorado, Minnesota, and Wisconsin in the Vaccine Safety Datalink. Children from age groups younger than 24 months and 4 to 6, 11 to 13, and 16 to 18 years were included if they had at least 1 week of health system enrollment from January 5, 2020, through October 3, 2020, over periods before the US COVID-19 pandemic (January 5, 2020, through March 14, 2020), during age-limited preventive care (March 15, 2020, through May 16, 2020), and during expanded primary care (May 17, 2020, through October 3, 2020). These individuals were compared with those enrolled during analogous weeks in 2019. Exposures: This study evaluated UTD status among children reaching specific ages in February, May, and September 2020, compared with those reaching these ages in 2019. Main Outcomes and Measures: Weekly vaccination rates for routine age-specific vaccines and the proportion of children UTD for all age-specific recommended vaccines. Results: Of 1 399 708 children in 2019 and 1 402 227 in 2020, 1 371 718 were female (49.0%) and 1 429 979 were male (51.0%); 334 216 Asian individuals (11.9%), 900 226 were Hispanic individuals (32.1%), and 201 619 non-Hispanic Black individuals (7.2%). Compared with the prepandemic period and 2019, the age-limited preventive care period was associated with lower weekly vaccination rates, with ratios of rate ratios of 0.82 (95% CI, 0.80-0.85) among those younger than 24 months, 0.18 (95% CI, 0.16-0.20) among those aged 4 to 6 years, 0.16 (95% CI, 0.14-0.17) among those aged 11 to 13 years, and 0.10 (95% CI, 0.08-0.13) among those aged 16 to 18 years. Vaccination rates during expanded primary care remained lower for most ages (ratios of rate ratios: <24 months, 0.96 [95% CI, 0.93-0.98]; 11-13 years, 0.81 [95% CI, 0.76-0.86]; 16-18 years, 0.57 [95% CI, 0.51-0.63]). In September 2020, 74% (95% CI, 73%-76%) of infants aged 7 months and 57% (95% CI, 56%-58%) of infants aged 18 months were UTD vs 81% (95% CI, 80%-82%) and 61% (95% CI, 60%-62%), respectively, in September 2019. The proportion UTD was lowest in non-Hispanic Black children across most age groups, both during and prior to the COVID-19 pandemic (eg, in May 2019, 70% [95% CI, 64%-75%] of non-Hispanic Black infants aged 7 months were UTD vs 82% [95% CI, 81%-83%] in all infants aged 7 months combined). Conclusions and Relevance: As of September 2020, childhood vaccination rates and the proportion who were UTD remained lower than 2019 levels. Interventions are needed to promote catch-up vaccination, particularly in populations at risk for underimmunization.

Resources and Geographic Access to Care for Severe Pediatric Pneumonia in Four Resource-limited Settings.

Rationale: Pneumonia is the leading cause of death in children worldwide. Identifying and appropriately managing severe pneumonia in a timely manner improves outcomes. Little is known about the readiness of healthcare facilities to manage severe pediatric pneumonia in low-resource settings. Objectives: As part of the HAPIN (Household Air Pollution Intervention Network) trial, we sought to identify healthcare facilities that were adequately resourced to manage severe pediatric pneumonia in Jalapa, Guatemala (J-GUA); Puno, Peru (P-PER); Kayonza, Rwanda (K-RWA); and Tamil Nadu, India (T-IND). We conducted a facility-based survey of available infrastructure, staff, equipment, and medical consumables. Facilities were georeferenced, and a road network analysis was performed. Measurements and Main Results: Of the 350 healthcare facilities surveyed, 13% had adequate resources to manage severe pneumonia, 37% had pulse oximeters, and 44% had supplemental oxygen. Mean (±SD) travel time to an adequately resourced facility was 41 ± 19 minutes in J-GUA, 99 ± 64 minutes in P-PER, 40 ± 19 minutes in K-RWA, and 31 ± 19 minutes in T-IND. Expanding pulse oximetry coverage to all facilities reduced travel time by 44% in J-GUA, 29% in P-PER, 29% in K-RWA, and 11% in T-IND (all P < 0.001). Conclusions: Most healthcare facilities in low-resource settings of the HAPIN study area were inadequately resourced to care for severe pediatric pneumonia. Early identification of cases and timely referral is paramount. The provision of pulse oximeters to all health facilities may be an effective approach to identify cases earlier and refer them for care and in a timely manner.

Estimativas de necessidade, oferta e distribuição territorial de leitos neonatais de terapia intensiva e de cuidado intermediário no estado do Rio de Janeiro, de 2012 a 2020 / Estimates of need, supply and territorial distribution of neonatal intensive care and intermediate care beds in the state of Rio de Janeiro, from 2012 to 2020

O cuidado intensivo neonatal é ferramenta essencial para a assistência de recém- nascidos graves ou potencialmente graves, a fim de diminuir a morbimortalidade neonatal. O objetivo do estudo foi analisar a oferta e distribuição territorial dos leitos intensivos e de cuidados intermediários neonatais, no estado do Rio de Janeiro, de 2012 a 2020 e estimar as necessidades e avaliar sua suficiência considerando o ano de 2020. Foi realizado estudo de caráter exploratório, correspondendo a uma avaliação normativa, com delineamento do tipo transversal e abordagem quantitativa. As fontes de dados utilizadas foram o CNES, para o levantamento dos leitos neonatais e suas modalidades, e o Sistema Nacional de Nascidos Vivos (SINASC-RJ) para obtenção do número de nascidos vivos (NV), em 2020. Para estimativa de necessidades e avaliação da suficiência de leitos neonatais, no ano de 2020, adotou-se os parâmetros propostos na Portaria GM/MS nº 930/2012. A estimativa de leitos necessários considerou dois cenários, onde o primeiro contemplou os usuários que utilizam exclusivamente o SUS (100% dos NV, excluídos os beneficiários de planos privados de saúde), e o segundo, 100% dos NV. Os resultados do estudo apontaram que, ao longo da série histórica, houve queda de 3,3% no total de leitos neonatais disponíveis ao SUS, aumento de 66,7% dos leitos de Unidade de Terapia Intensiva Neonatal (UTIN) tipos II e III disponíveis ao SUS, e redução dos leitos de UTIN I. Os leitos de cuidado intermediário neonatal convencional (UCINCo), que representaram a maior parte dos leitos de cuidado intermediário, tiveram redução de cerca de 43%. Os leitos de cuidados intermediários canguru, que constituíram parcela pequena dos leitos neonatais em toda a série histórica (média de 4%), tiveram aumento progressivo ao longo do período estudado. Verificou-se suficiência dos leitos de terapia intensiva no ano de 2020, mas com desigualdades regionais importantes. Foram apontados déficits tanto de leitos de convencionais quanto canguru (UCINCa), estes últimos com situação deficitária em todas as regiões do Estado. Conclui-se que as regiões não estão organizadas sob uma linha de cuidados progressivos, com as três tipologias de leitos previstas na legislação. Há necessidade de investimento na Rede Neonatal estadual, com ampliação dos leitos de todas as modalidades, de forma regionalizada, a fim de melhorar o acesso, evitar o transporte do RN e contribuir para a redução da morbimortalidade neonatal. O estudo pode trazer subsídios ao planejamento dentro da área de cuidado neonatal, baseado na equidade no acesso aos leitos disponíveis no SUS, em particular no Estado do Rio de Janeiro.

Neonatal intensive care is an essential tool for the aid of newborns in serious or potentially serious conditions, in order to reduce neonatal morbidity and mortality. The purpose of this study was to analyze the supply and territorial distribution of intensive and intermediate neonatal care beds in the state of Rio de Janeiro, from 2012 to 2020, estimate their needs and evaluate their sufficiency for the year 2020. It was an exploratory study, corresponding to a normative assessment, with a cross-sectional design and a quantitative approach. The databases used were National Register Health Establishments (CNES) for the survey of neonatal beds and their modalities, and the National Live Birth System (SINASC-RJ) for obtaining the number of live births (LB) in 2020. In order to estimate needs and assess the sufficiency of neonatal beds, in 2020, the parameters proposed in Ordinance GM/MS number 930/2012 were used as a basis. The estimate of beds needed was based on two scenarios, in which the first considered who exclusively uses the SUS (100% of LB, excluding beneficiaries of private health insurance), and the second, 100% of LB. The results of the study showed that, throughout the historical series, there was a 3.3% decrease in the total number of neonatal beds available to SUS, an increase of 66.7% in the number of beds of Neonatal Intensive Care Unit types II and III, available to SUS, and a reduction of beds in Neonatal Intensive Care Unit type I. Neonatal Conventional Intermediate Care beds, which accounted for the majority of intermediate care beds, were reduced about 43%. The kangaroo intermediate care beds, which represented a small portion of neonatal beds throughout the historical series (average of 4%), had a progressive increase over the study`s period. This research observed that there is a sufficiency of intensive care beds, in 2020, but concerning regional inequalities. As for the intermediate care beds, deficits were identified in both conventional and kangaroo beds, the latter with a deficit situation in all regions. It is concluded that the regions are not organized under a progressive care line, with the three types of beds provided for in the legislation. Therefore, there is a need for investment in the state Neonatal Network, with expansion of beds of all modalities, in a regionalized way, in order to improve access, avoid the transportation of the newborns and contribute to reduce neonatal morbidity and mortality. To summarize, the study can provide, to the health system and researchers, subsidies for planning within the area of neonatal care, based on equity in access to beds available at SUS, particularly in the State of Rio de Janeiro.