Medication use and health care contacts among symptomatic children with asthma.

OBJECTIVE: Asthma morbidity and mortality continue to increase despite the availability of improved therapies. Little is known about the degree to which children with asthma use medications and health care services during symptomatic periods. This study documents prospectively the use of medications and health care contacts among children with active asthma symptoms. METHODS: Children age 6--19 years from 11 primary care settings in upstate New York were eligible for this study if they had 3 or more asthma-related medical visits during the prior year. We collected extensive information on asthma symptoms, medication use, and contacts with health care providers from biweekly phone interviews and daily diaries during a 3-month period. Symptoms were evaluated as the average number of symptomatic days per week. We tabulated the proportion of children using anti-inflammatory medications and having health care contacts according to the frequency of their symptoms during this 3-month period. Chi-square and regression analyses were used. RESULTS: One hundred sixty-five children participated (67% White, 24% Black, 9% Other). Sixty-five percent of the children in this sample had an average of more than 2 symptomatic days per week or more than 2 symptomatic nights per month during the 3-month study period and thus had mild persistent to severe asthma. Among these children, 25% received prednisone, and 46% reported the use of an inhaled maintenance medication during the monitoring period. Ten percent of children in this sample experienced an average of 6 or more symptomatic days per week during the study period. Among these highly symptomatic children, only 19% received prednisone, and 56% used a maintenance medication. Further, the proportion of children having contact with a health care provider during this 3-month period was 50% or less, even among the children experiencing the most frequent asthma symptoms. There were no differences in the proportion of children with health care contacts, prednisone use, or maintenance anti-inflammatory use among different gender or race categories or with different insurance types or places of residence. CONCLUSIONS: Even among children experiencing almost daily asthma symptoms, inadequate anti-inflammatory therapy is common, and few contacts with health care providers occur. These children are silently suffering at home and likely are experiencing preventable morbidity.

Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence.

CONTEXT: Home visitation to families with young children has been promoted as an effective way to prevent child maltreatment, but few studies have examined the conditions under which such programs meet this goal. OBJECTIVE: To investigate whether the presence of domestic violence limits the effects of nurse home visitation interventions in reducing substantiated reports of child abuse and neglect. DESIGN: Fifteen-year follow-up study of a randomized trial. SETTING: Semirural community in upstate New York. PARTICIPANTS: Of 400 socially disadvantaged pregnant women with no previous live births enrolled consecutively between April 1978 and September 1980, 324 mothers and their children participated in the follow-up study. INTERVENTIONS: Families were randomly assigned to receive routine perinatal care (control group; n = 184 participated in follow-up), routine care plus nurse home visits during pregnancy only (n = 100), or routine care plus nurse home visits during pregnancy and through the child's second birthday (n = 116). MAIN OUTCOME MEASURES: Number of substantiated reports over the entire 15-year period involving the study child as subject regardless of the identity of the perpetrator or involving the mother as perpetrator regardless of the identity of the child abstracted from state records and analyzed by treatment group and level of domestic violence in the home as measured by the Conflict Tactics Scale. RESULTS: Families receiving home visitation during pregnancy and infancy had significantly fewer child maltreatment reports involving the mother as perpetrator (P =. 01) or the study child as subject (P =.04) than families not receiving home visitation. The number of maltreatment reports for mothers who received home visitation during pregnancy only was not different from the control group. For mothers who received visits through the child's second birthday, the treatment effect decreased as the level of domestic violence increased. Of women who reported 28 or fewer incidents of domestic violence (79% of sample), home-visited mothers had significantly fewer child maltreatment reports during the 15-year period than mothers not receiving the longer-term intervention (P =.01). However, this intervention did not significantly reduce child maltreatment among mothers reporting more than 28 incidents of domestic violence (21% of sample). CONCLUSIONS: The presence of domestic violence may limit the effectiveness of interventions to reduce incidence of child abuse and neglect. JAMA. 2000;284:1385-1391.

Enduring effects of nurse home visitation on maternal life course: a 3-year follow-up of a randomized trial.

CONTEXT: A home visitation program using nurses to improve maternal and child outcomes had favorable results in a randomized trial with a primarily white, semirural population. Many of the short-term findings have been replicated with urban blacks, but whether the program will continue to demonstrate effectiveness after its conclusion is uncertain. OBJECTIVE: To determine the effectiveness of a prenatal and infancy home visitation program on the maternal life course of women in an urban environment 3 years after the program ended. DESIGN AND SETTING: Three-year follow-up of a randomized controlled trial of women seen consecutively between June 1990 and August 1991 at an obstetrical clinic in Memphis, Tenn, who were enrolled in a visitation program for 2 years after the birth of their first child. PARTICIPANTS: A cohort of 743 women who were primarily black, were pregnant for less than 29 weeks, had no previous live births, and had at least 2 sociodemographic risk factors (unmarried, <12 years of education, or unemployed). INTERVENTION: An average of 7 (range, 0-18) home visits during pregnancy and 26 (range, 0-71) from birth to the child's second birthday. MAIN OUTCOME MEASURES: Rate of subsequent pregnancy, mean interval between first and second birth, and mean number of months of welfare use. RESULTS: Compared with the control group, women who received home visits by nurses had fewer subsequent pregnancies (1.15 vs 1.34; P=.03), fewer closely spaced subsequent pregnancies (0.22 vs 0.32; P=.03), longer intervals between the birth of the first and second child (30.25 vs 26.60 months; P=.004), and fewer months of using Aid to Families with Dependent Children (32.55 vs 36.19; P=.01) and food stamps (41.57 vs 45.04; P=.005). Compared with the effect of the program while the program was in operation, the effect after it ended was essentially equal for Aid to Families with Dependent Children, greater for food stamps, greater for rates of closely spaced subsequent pregnancies, and smaller for rates of subsequent pregnancy overall. CONCLUSIONS: We found enduring effects of a home visitation program on the lives of black women living in an urban setting. While these results were smaller in magnitude than those achieved in a previous trial with white women living in a semirural setting, the direction of the effects was consistent across the 2 studies.

Delayed first pregnancy among African-American adolescent smokers.

PURPOSE: This study aimed to compare rates of adolescent pregnancy among African-American adolescents who began smoking as adolescents with those who did not. METHODS: Cross-sectional data on 1042 primiparous African-American women enrolled in a randomized clinical trial of nurse home visitation were examined. The independent variable, adolescent smoking, was defined as a report of smoking before the age of 18 years. The outcome variable was adolescent pregnancy, defined as first pregnancy before the age of 18 years. Logistic regression was used to control for potential confounders. RESULTS: After adjustments for drug use, use of contraception, frequency of coitus, and sexually transmitted diseases, women who smoked during adolescence had a 50% lower risk of becoming pregnant as an adolescent [odds ratio of 0.46 (95% confidence interval [CI] 0.27-0.76)]. When time to first pregnancy was examined as a continuous variable, adolescent smoking was associated with a delay in pregnancy of 22.6 months (95% CI 16.8-29.2). CONCLUSIONS: Teen smoking appears to be associated with a significantly lower rate of adolescent pregnancy among African-Americans. Although the nature of this relationship is unclear, this finding suggests the need for linkage between smoking prevention and adolescent pregnancy prevention.

PIP: Adolescent smoking has been linked to adolescent risk-taking behavior, including earlier and unprotected sexual activity, and drug use. The authors compared rates of adolescent pregnancy among Black adolescents who began smoking as adolescents against the rates of those who did not. Adolescent smoking was defined as a report of smoking before reaching age 18 years, while adolescent pregnancy was defined as pregnancy to women under age 18. Cross-sectional data on 1042 primiparous Black women enrolled in a randomized clinical trial of nurse home visitation were examined. Women in the study sample were aged 12-33 years, of mean age 17.9 years, at enrollment, 99% were unmarried, 85% were below 100% of the federal poverty level, and they had 10.2 mean years of education. After adjusting for drug use, contraceptive use, frequency of coitus, and infection with sexually transmitted diseases, women who smoked cigarettes during adolescence had a 50% lower risk of becoming pregnant as adolescents. When time to first pregnancy was examined as a continuous variable, adolescent smoking was associated with a delay in pregnancy of 22.6 months. These findings are consistent with previously reported findings based mainly upon adult White women. The nature of this relationship is unclear, but the data alone cannot establish causation between adolescent smoking and delay in pregnancy.

Long-term effects of nurse home visitation on children's criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial.

CONTEXT: A program of home visitation by nurses has been shown to affect the rates of maternal welfare dependence, criminality, problems due to use of substances, and child abuse and neglect. However, the long-term effects of this program on children's antisocial behavior have not been examined. OBJECTIVE: To examine the long-term effects of a program of prenatal and early childhood home visitation by nurses on children's antisocial behavior. DESIGN: Fifteen-year follow-up of a randomized trial. Interviews were conducted with the adolescents and their biological mothers or custodial parents. SETTING: Semirural community in New York. PARTICIPANTS: Between April 1978 and September 1980, 500 consecutive pregnant women with no previous live births were recruited, and 400 were enrolled. A total of 315 adolescent offspring participated in a follow-up study when they were 15 years old; 280 (89%) were born to white mothers, 195 (62%) to unmarried mothers, 151 (48%) to mothers younger than 19 years, and 186 (59%) to mothers from households of low socioeconomic status at the time of registration during pregnancy. INTERVENTION: Families in the groups that received home visits had an average of 9 (range, 0-16) home visits during pregnancy and 23 (range, 0-59) home visits from birth through the child's second birthday. The control groups received standard prenatal and well-child care in a clinic. MAIN OUTCOME MEASURES: Children's self-reports of running away, arrests, convictions, being sentenced to youth corrections, initiation of sexual intercourse, number of sex partners, and use of illegal substances; school records of suspensions; teachers' reports of children's disruptive behavior in school; and parents' reports of the children's arrests and behavioral problems related to the children's use of alcohol and other drugs. RESULTS: Adolescents born to women who received nurse visits during pregnancy and postnatally and who were unmarried and from households of low socioeconomic status (risk factors for antisocial behavior), in contrast with those in the comparison groups, reported fewer instances (incidence) of running away (0.24 vs 0.60; P = .003), fewer arrests (0.20 vs 0.45; P = .03), fewer convictions and violations of probation (0.09 vs 0.47; P<.001), fewer lifetime sex partners (0.92 vs 2.48; P= .003), fewer cigarettes smoked per day (1.50 vs 2.50; P= .10), and fewer days having consumed alcohol in the last 6 months (1.09 vs 2.49; P = .03). Parents of nurse-visited children reported that their children had fewer behavioral problems related to use of alcohol and other drugs (0.15 vs 0.34; P = .08). There were no program effects on other behavioral problems. CONCLUSIONS: This program of prenatal and early childhood home visitation by nurses can reduce reported serious antisocial behavior and emergent use of substances on the part of adolescents born into high-risk families.

Does child abuse predict adolescent pregnancy?

OBJECTIVE: To determine whether sexual and nonsexual childhood abuse are risk factors for early adolescent sexual activity and pregnancy. DESIGN; Cross-sectional study. SETTING: Prenatal clinic within an inner-city teaching hospital from June 1990 to August 1991. POPULATION: One thousand twenty-six primiparous, African-American women enrolled in a randomized clinical trial of nurse home visitation. MAIN OUTCOME MEASURES: Four measures of child abuse were used: sexual abuse, incidents of physical abuse, any major physical abuse, and emotional abuse. The outcome measures were age of first consensual coitus and age of first pregnancy. RESULTS: After adjustments for household income, parental separation, urban residence, age of menarche, and teen smoking, sexual abuse during childhood was associated with younger age at first coitus (7.2 months; 95% confidence interval [CI], 2.6 to 11.7 months) and younger age at first pregnancy (9.7 months; 95% CI, 3.0 to 16.3 months). Incidents of physical abuse showed minimal effect on age at first coitus (1.2 days per incident; 95% CI, 0.5 to 1.9 days) and no effect on age of first pregnancy. A history of major physical abuse or emotional abuse showed no effect on age of first coitus or first pregnancy. CONCLUSION: Child sexual abuse, but not child physical or emotional abuse, seems to be a risk factor for earlier pregnancy among African-American adolescents.

Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial.

CONTEXT: Home-visitation services have been promoted as a means of improving maternal and child health and functioning. However, long-term effects have not been examined. OBJECTIVE: To examine the long-term effects of a program of prenatal and early childhood home visitation by nurses on women's life course and child abuse and neglect. DESIGN: Randomized trial. SETTING: Semirural community in New York. PARTICIPANTS: Of 400 consecutive pregnant women with no previous live births enrolled, 324 participated in a follow-up study when their children were 15 years old. INTERVENTION: Families received a mean of 9 home visits during pregnancy and 23 home visits from the child's birth through the second birthday. DATA SOURCES AND MEASURES: Women's use of welfare and number of subsequent children were based on self-report; their arrests and convictions were based on self-report and archived data from New York State. Verified reports of child abuse and neglect were abstracted from state records. MAIN RESULTS: During the 15-year period after the birth of their first child, in contrast to women in the comparison group, women who were visited by nurses during pregnancy and infancy were identified as perpetrators of child abuse and neglect in 0.29 vs 0.54 verified reports (P<.001). Among women who were unmarried and from households of low socioeconomic status at initial enrollment, in contrast to those in the comparison group, nurse-visited women had 1.3 vs 1.6 subsequent births (P=.02), 65 vs 37 months between the birth of the first and a second child (P=.001), 60 vs 90 months' receiving Aid to Families With Dependent Children (P=.005), 0.41 vs 0.73 behavioral impairments due to use of alcohol and other drugs (P=.03), 0.18 vs 0.58 arrests by self-report (P<.001), and 0.16 vs 0.90 arrests disclosed by New York State records (P<.001). CONCLUSIONS: This program of prenatal and early childhood home visitation by nurses can reduce the number of subsequent pregnancies, the use of welfare, child abuse and neglect, and criminal behavior on the part of low-income, unmarried mothers for up to 15 years after the birth of the first child.

Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial.

CONTEXT: Interest in home-visitation services as a way of improving maternal and child outcomes has grown out of the favorable results of a trial in semirural New York. The findings have not been replicated in other populations. OBJECTIVE: To test the effect of prenatal and infancy home visits by nurses on pregnancy-induced hypertension, preterm delivery, and low birth weight; on children's injuries, immunizations, mental development, and behavioral problems; and on maternal life course. DESIGN: Randomized controlled trial. SETTING: Public system of obstetric care in Memphis, Tenn. PARTICIPANTS: A total of 1139 primarily African-American women at less than 29 weeks' gestation, with no previous live births, and with at least 2 sociodemographic risk characteristics (unmarried, <12 years of education, unemployed). INTERVENTION: Nurses made an average of 7 (range, 0-18) home visits during pregnancy and 26 (range, 0-71) visits from birth to the children's second birthdays. MAIN OUTCOME MEASURES: Pregnancy-induced hypertension, preterm delivery, low birth weight, children's injuries, ingestions, and immunizations abstracted from medical records; mothers' reports of children's behavioral problems; tests of children's mental development; mothers' reports of subsequent pregnancy, educational achievement, and labor-force participation; and use of welfare derived from state records. MAIN RESULTS: In contrast to counterparts assigned to the comparison condition, fewer women visited by nurses during pregnancy had pregnancy-induced hypertension (13% vs 20%; P=.009). During the first 2 years after delivery, women visited by nurses during pregnancy and the first 2 years of the child's life had fewer health care encounters for children in which injuries or ingestions were detected (0.43 vs 0.55; P=.05); days that children were hospitalized with injuries or ingestions (0.03 vs 0.16; P<.001); and second pregnancies (36% vs 47%; P=.006). There were no program effects on preterm delivery or low birth weight; children's immunization rates, mental development, or behavioral problems; or mothers' education and employment. CONCLUSION: This program of home visitation by nurses can reduce pregnancy-induced hypertension, childhood injuries, and subsequent pregnancies among low-income women with no previous live births.