\\ 1“ ~ / STUDIES ON INSTITUTIONS AND PLANNING research to improve health services for mothers and chzldre'n U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services Administration Bureau of Community Health Services Rockville, Maryland 20857 STUDIES ON L3 ~ INSTITUTIONS AND PLANNINGJ research to improve health services for mothers and children U.S. DEPARTMENT OF HEALTH. EDUCATION,AND WELFARE Public Health Service Health Services Administration Bureau of Community Health Services Rockville, Maryland 20857 DHEW Publication No. (HSA) 77-5704 1977 MCH RESEARCH PUBLICATIONS The Maternal and Child Health Service Reports on Research To Improve Health Services for Mothers and Children, DHEW Publication No. (HSM) 73-5116 MCH Research Series No. 2: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 74-5120 MCH Research Series No. 3: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 74-5121 MCH Research Series No. 4: Research To Improve Health Services for Mothers and Children, DHEW Publication No. (HSA) 74-5122 MCH Research Series No. 5: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 74-5123 International MCH Projects: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 75-5129 Studies in Handicapping Conditions: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 75- 5131 Studies in Maternal Health: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 75-5132 Studies in Child Health: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 76-5133 International MCH Projects—ll: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 77-5700 Studies in Adolescent Health: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 77-5701 Studies in Maternal Health—II: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 77-5702 Studies on Delivery Systems: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 77-5703 Studies on Institutions and Planning: Research To Improve Health Services for Mothers and Children. DHEW Publication No. (HSA) 77- 5704 ii XC“) 950i PUBl. FOREWORD (jg-42:? H77 This publication is one in a series presenting summaries of the final P081, reports of research projects concerned with improving the operation, functioning, and effectiveness of health services for mothers and children and for crippled children. These research projects are funded by the Office for Maternal and Child Health of the Bureau of Community Health Services, Health Services Administration, under the 1963 amendments to title V of the Social Security Act (Public Law 88- 156). Initially, the research grants were administered by the Children’s Bureau and later by the Maternal and Child Health Service. The research projects have produced a number of major findings that have practical applications in local and State programs of maternal and child health. Federal, State, and local health agencies and individual workers are encouraged to adopt or adapt these findings to their own programs for mothers and children. Summaries of research projects were prepared by the Maternal and Child Health Program, School of Public Health, University of California, Berkeley, under MCHS grant MGR-060208. Readers interested in more detailed information about the studies should direct their requests to the principal researchers of the projects. PROJECTS CHILD CARING: SOCIAL POLICY AND THE INSTITUTION DONNELL M. PAPPENFORT, DEE MORGAN KILPATRICK, and ROBERT W. ROBERTS, UNIVERSITY OF CHICAGO, ILLINOIS A SYSTEM FOR PLANNING AND ACHIEVING COMPREHENSIVE HEALTH CARE IN RESIDENTIAL INSTITUTIONS FOR THE MENTALLY RETARDED HAROLD A. DECKER, M.D.. UNIVERSITY OF MICHIGAN, ANN ARBOR MEDICAL NEEDS OF CHILDREN IN INSTITUTIONS FOR THE MENTALLY RETARDED DONALD C. SMITH, M.D., HAROLD A. DECKER, M.D., MARY S. HAYTHORNTHWAITE, M.D., CH.B., EDWARD N. HERBERT, M.S.S., and LOIS K. RUPE, R.N., UNIVERSITY OF MICHIGAN, ANN ARBOR HEALTH NEEDS AND HEALTH CARE OF CHILDREN IN DAY CARE ANN DEHUFF PETERS, UNIVERSITY OF NORTH CAROLINA, CHAPEL HILL DEVELOPMENT OF A COMMUNITY-WIDE HEALTH INFORMATION SYSTEM TO ASSIST IN MATERNAL AND CHILD HEALTH PROGRAM PLANNING ESTELLE SIKER, MD, MPH, JOHN C. DESHAIES, M.A., and SAMUEL P. KORPER, M.P.H., CONNECTICUT STATE DEPARTMENT OF HEALTH, NEW HAVEN MOTHERS AND CHILDREN RECEIVING PUBLIC ASSISTANCE FROM THE MIDWAY DISTRICT OFFICE Dee Morgan Kilpatrick and EDWARD E. SCHWARTZ, UNIVERSITY OF CHICAGO, ILLINOIS CHILD CARING: SOCIAL POLICY AND THE INSTITUTION DONNELL M. PAPPENFORT, DEE MORGAN KILPATRICK, and ROBERT W. ROBERTS, Editors, University of Chicago, Illinois, 1971, Grant Nos. MC- R-170017 and PH-I400 Although thousands of children reside in institutions in the United States, little has been known about them or the programs and resources of agencies responsible for their care. The first comprehensive national survey of the services and programs of these institutions was conducted in 1966. The National Survey of Residential Child Care Facilities covered 2,318 public and private institutions that were providing care to 155,905 children and youth. Included were institutions for dependent and neglected, predelinquent or delinquent, and emotionally disturbed children; psychiatric inpatient children’s units; maternity homes; temporary shelters; and detention facilities. ”Child Caring: Social Policy and the Institution," which was published by Aldine Publishing Company, Chicago, in 1973, evolved from the 1966 survey. The papers in this volume were commissioned by the Project on Physical Facilities for Group Care of Children, the Center for Urban Studies at the University of Chicago. To maximize the effect of the study, the Maternal and Child Health Service of the US. Department of Health, Education, and Welfare adopted a 3-step plan. The first step was to commission papers by social welfare planners who were professionally identified with each of the types of institutions surveyed. They were to study the survey data relevant to their areas of interest; assess the current status of these institutions; and develop policies, programs, and plans for the future. The second step was to convene a small working conference of scholars representing broad and diverse perspectives in the child health field who could review these suggested policies and programs, and incorporate their own recommendations. The conference was held in 1971, under the joint sponsorship of the Center for Urban Studies and the Center for the Study of Welfare Policy, School of Social Service Administration, University of Chicago. The third step was to publish the papers together so that findings and recommendations would be available to organizations and individuals who provide leadership for change. “Child Caring: Social Policy and the Institution” represents the fulfillment of the third strategy. Section I, entitled “Perspectives on Institutions for Children,” contains three papers prepared as resource material for the conference: 1. “Institutions for Dependent and Delinquent Children: Histories, Nineteenth-Century Statistics, and Recurrent Goals,” by Rachel B. Marks, summarizes historical documents and examines statistics of institutions for dependent and delinquent children in the nineteenth- century United States. 2. “The Benevolent Asylum: Some Theoretical Observations on Institutional Care,” by Martin Wolins, presents an analysis of the kinds of asylum environments that are present in different societies, and a description of the ideologies behind them. For example, an asylum that requires dependency of its inmates will have different kinds of relationships, dangers, and social sanctions than an institution such as a kibbutz, that requires its members to be other-oriented. The paper includes a section on “The Problem of Professionals” and another on “The Crucial Role of Peers." 3. “Research on Child-Caring Institutions,” by Ann W. Shyne, examines current literature in child development and related fields and suggests ways for institutions to provide better environments for growing children. The five papers in Section II, “Policy and Planning Issues: Specific Types of Institutions,” use empirical data about institutions and their social contents as a basis for formulating suggestions for revisions of policies, reorganization of services, and changes in philosophies of care for each type of children’s institution. 1. “Institutions for Dependent and Neglected Children,” by Alfred Kadushin, examines potential users of substitute care and trends affecting their future needs. The population with the greatest risk of needing substitute care, he concludes, is made up of poverty-level families headed by a female. The rate of children referred to institutions for the dependent and neglected appears to have stabilized during the past decade after a long period of decline. The relative distribution of children receiving substitute care has slowly been changing in favor of foster family care rather than institutional care. 2. “Institutions for Predelinquent or Delinquent Children," by Lloyd E. Ohlin, defines the nature of the delinquency problem and outlines some types of intervention. He points out the emerging consensus among professional groups about the necessity and desirability of developing a variety of small residential institutions and homes for delinquent youth. 3. “Institutions with Therapeutic Residential Programs for Children,” by Samuel H. Taylor, deals with the need of children for residential psychiatric care and the shortcomings of care presently available. The paper suggests improved coordination and integration of service networks, and training in the design of health care systems for both staff and administrative personnel. 4. “Institutions for Unmarried Pregnant Girls,” by Samuel Miller, proposes remedies to the fragmentation of resources that results in unequal and inadequate care for unwed mothers and looks at ways of increasing the resources available. 5. “Detention Facilities and Temporary Shelters,” by Margaret K. Rosenheim, argues against confining all juvenile delinquents in the same institution. Although all adolescents are under the jurisdiction of the same juvenile courts, their age range reflects two different kinds of delinquents. She proposes eliminating detention for most youthful offenders, utilizing temporary shelters for brief housing or diagnostic evaluation needs, and placing older offenders with young adults for long-term care. Section III, “Policy and Planning Issues: An Overview," by Alfred J. Kahn, summarizes the discussions and suggestions made during the conference. 1. From any perspective, much institutional care is in bad shape. Detention facilities are a prime example. 2. Too often the costs of buildings are so high that there is not enough budget left to make the program effective. 3. Institutions need not be bad. When they are, we know enough to make them better. 4. The crucial element in reform strategy is making group care—part or all day, brief or long term—a more acceptable element is “normal” childrearing. Such a strategy would launch a series of urgent reforms. 5. Helpful institutional care is available in some areas, but children in too many parts of the country are deprived. 6. Far too often, research in the child welfare field compares “good” family care with “poor” institutional care. More careful examination of the facts would decrease the inhibition to use group care for children. 7. Many institutions could become more useful if they invested less heavily in what are thought of as formal “treatment” resources and built up their capabilities for wholesome child-rearing. 8. Dilemmas relating to the underuse and misuse of group care and to the causes of success and failure in institutions can be dealt with adequately only in the context of developing an integrated system of social services. Group care should be integrated into such a service network. 9. Case service networks (services dealing with problems and breakdown) will not meet all social concerns for families and children. While not abnegating responsibility to improve institutions, we would also emphasize a greater commitment to family policy and clarification of the implications of such a policy. 10. Social intervention comes from trial runs and diverse experience. There is a need to do many new things in this field, which in many ways is operating poorly and irrationally. 11. While more and better group care is needed, the network notion suggests that we do not need an independent institutional system. 12. Coercive institutions are extremely difficult to run successfully. They should be employed less often, for fewer youths, and probably not at all for young children. 13. Although most of the proposals seem to focus on the very young, it is not because of failure to recognize the degree of national concern with adolescents. Impressive policy and service models pertaining to adolescents are difficult to find and the need for imagination, innovation, and broad perspective is overwhelmingly evident. A SYSTEM FOR PLANNING AND ACHIEVING COMPREHENSIVE HEALTH CARE IN RESIDENTIAL INSTITUTIONS FOR THE MENTALLY RETARDED HAROLD A. DECKER, M.D., Department of Health Development, School of Public Health, University of Michigan, Ann Arbor, 1970. Grant Nos. PC- 1001 (C1), PH-IOOO, and PH-43-67-1454. Until a few decades ago, mildly retarded patients without physical handicaps constituted the bulk of cases in residential institutions for the mentally retarded. Health care in institutions, as in the society at large, was typically directed toward symptomatic relief from episodes of actual illness, or the management of traumatic injury. Now the severely and profoundly retarded with multiple physical and sensory defects predominate in most institutions. The new complexity of health problems and the techniques and medical systems developed to deal with them require that institutions adopt new organizational patterns for meeting health needs. This research project planned a system for delivering comprehensive, individualized health care to mentally retarded residents of institutions in order to maximize the development of their health and social function. This standardized health care system is the culmination of 5 years of surveying health care in State residential institutions for the retarded. (See next abstract.) Clinical Appraisal In this system, the first step leading to individualized health care is appraisal of each patient's present clinical status. Some areas that often appear difficult to determine from the medical record are: the patient’s strengths, the total degree of disability, whether the clinical condition is improving or deteriorating, and the degree and rate of change over a period of time. The investigator recommends that the physician supplement his examination with reports prepared by persons who work with the patient daily; by clinical photographs; psychometric, education, and vocational tests; and measurement of the severity of a condition by laboratory tests and clinical specialties. The investigator outlines 10 essential processes in the system for analyzing the “whole” patient. Included in the proposed system are data on the patient’s strengths and individual needs, for medical and habilitative care, as well as a plan for synthesizing and implementing the information gained into a total care plan. The procedures are: Form I—The Health Questionnaire Form 2—The Functioning Questionnaire Form 3—The Summary of Current Care Program Form 4—The Multiphasic Screening Form 5—Clinical Pathology Form 6—Physical Examination by Primary Care Physician Form 7—Special Consultation Form 8—Physician Summary Prepared by Primary Care Physician (based on physician review of residents records and reports of other professions) Form 9—Summary of Health and Habilitation Status Goals, and Care Plans—obtained from a conference resulting in: 1. A comprehensive summary of resident’s status (problems and strengths). 2. Health care and habilitation goals (problem oriented). 3. A comprehensive management plan (oriented to problems and goals). Form lO—Summaries of Evaluation by Psychologist, Social Worker, and Others (using forms analogous to Forms 7 and 8). Form 1, patterned after the medical history, is filled out by a close acquaintance, such as the cottage parent. The questions in this form initially use only “yes," “no” answers and are later supplemented by a short interview by the physician with the cottage parent. Attendents or nurses fill out Form 2, which is designed to provide the physician with an estimate of the resident’s functioning level in common activities of daily living. On Form 3 the cottage parent summarizes the resident’s current care program (daily activities engaged in and services received), which serves as a foundation for planning an improved care program. Form 4 exemplifies a set of procedures appropriate for a multiphasic screening program for retarded children in institutions. The procedures were selected by caretaking staff according to their feasibility and economy, as well as their potential for discovering disease that is amenable to cure or control. This form serves not only as a checklist and order form, but also as a concise record of immunizations, screening results, and the primary physician’s comments and plans for followup. As with historical data, it is essential for a physician to review these screening results and evaluate their significance. Form 5 could be used both for ordering and for filing clinical photographs. The author notes that in view of its descriptive power, photography is used surprisingly little in the clinical records of institutions. Not only can a photograph capture detail concerning visible abnormalities, but it can record normal features of the examination as well. Form 6 presents a prestructured examination record which requires a minimum of time for completion by the primary-care physician. The form lists body regions and organ systems in the standard way, with the notable addition of several facets that are particularly likely to be important in this population, such as teeth and gingivae; the skin; and pelvic, rectal, and neurological examinations. On this form, a checkmark beside the area of examination signifies the need for specialty consultation. Form 7 presents a report which can increase the information yield of consultations. The form is structured in a manner which enables the referring physician to provide effective direction for the consultation. It also encourages the consultant to describe anatomic, physiological, and functional abnormalities in a quantitative way; to establish therapeutic goals in similar terms; to schedule a complete therapeutic program; and to schedule continual specialty followup and reevaluation of progress. Of the consultant referrals examined, 18 percent were to psychologists, 12 percent to orthopedists; 1 1 percent to otologists, 1 1 percent to neurologists, and 10 percent to ophthalmologists. After completing the physical examination and obtaining any necessary consultations, the primary physician must integrate all the information from questionnaires, screening, examination, and consultation into a coherent summary statement of health status. Ideally, this summary would point out clearly the therapeutic goals and methods that should be pursued. Form 8 provides a sample format for such a document. The Resident-Care-Planning Conference The health status assessment is wasted if the information is not subsequently integrated and utilized to plan the resident’s future care. The next step in this health care delivery system should be the resident- care-planning conference in which all the data in Forms 1—8 are discussed. This conference results in Form 9, the Summary of Health and Habilitation Status, Goals, and Care Plans. As previously noted, institutions generally require evaluation of every retarded resident by at least his physician, social worker, a psychologist, and his cottage parent. In some institutions every resident also received evaluation by a nurse, a special educator, and/or some other discipline; other disciplines can be added as needed. Though it is possible for clinicians in various disciplines to prepare the therapeutic plan individually, the investigator concluded from previous research that a more explicit, detailed, and comprehensive plan results from a conference between these disciplines. In addition, preparing a detailed care plan in writing facilitates turning the implementation of the plan over to auxiliary personnel. The author recommends that participants of the resident-care- planning conference consist of a team of service-line workers, who would be carrying out the service plan and have regular contact with the patients, rather than the chiefs of professional divisions within the institution. This means all conference participants are personally acquainted with the resident being discussed and the need to spend time exchanging background information is alleviated. Also, it enables an institution to have several such conference groups. This team would meet a specified number of times per week, 4 hours at a time. The author recommends that meetings be frequent enough to review each resident of the institution at least every 2 years, and estimates that each case would require about 1 hour of conference time. The agenda of the conference for each case would be as follows: 0 Identification of the Topic Resident 0 Summary of Reports Concerning the Resident’s Clinical Status 0 Listing the Resident's Problems and Strengths (Form 9) 0 Formulation of a Comprehensive Set of Health and Habilitation Goals (Form 9) 0 Formulation of a Comprehensive Health and Habilitation Service Plan (Form 9). To keep the conference evaluation operations efficient and effective, it is necessary to have an organizer watch over the process, record the conference, and coordinate implementation of the care plans. For these reasons a carefully selected and specially trained service coordinator should be included on the basic health care team. In order to integrate the procedures of this health care system, the service coordinator would collect all evaluation reports, inspect them for completeness, and arrange for all ordered consultations and tests. He or she would schedule the conferences and keep a record of their proceedings. After the conference, he or she would coordinate the services that need to be delivered to the resident, arrange for extramural activities where required, and organize services to be provided from the community and nearby educational facilities. The coordinator would assist administration in defining problems in the care system and their solutions. These requests for additional service would provide backup statistics, documenting the budgetary requests of the institution administrator. Finally, the coordinator would provide interface between the clinical personnel and the data processing system, so that the data system could be used to schedule followup care and provide reminders when the care was not implemented. Conclusions The investigator concludes that an important prerequisite to the success of this system is widespread support by all classes and levels of institutional employees. After support has been achieved, staff training should be scheduled, particularly for those who participate in the collection of evaluative data. Finally, it would be necessary to evaluate the effectiveness of this system in proportion to its cost. The investigator suggests that the proposed system can be useful to any institution willing to revise its delivery of care system in order to help its residents achieve their maximum potential. Reprints may be obtained from the author, c/o Department of Pediatrics, University of Arkansas Medical Center, Little Rock, Arkansas 72201. MEDICAL NEEDS OF CHILDREN IN INSTITUTIONS FOR THE MENTALLY RETARDED DONALD C. SMlTH, M.D., HAROLD A. DECKER, M.D., MARY S. HAYTHORNTHWAITE, M.D., CH.B., EDWARD N. HERBERG, M.S.S., and LOIS K. RUPKE, R.N., Department of Health Development, School of Public Health, University of Michigan, Ann Arbor, 1967. Grant No. PH- 1000. This project was a descriptive and comparative study of the health status of different groups of children in mental institutions. The objectives were: 1. To describe the populations of retarded children according to: 0 Demographic characteristics. 0 Etiology and character of retardation. 0 Medical conditions associated with mental retardation. 0 Need for medical care. 2. To describe the problems in obtaining care and to offer solutions in overcoming them. 3. To evaluate what medical and social progress is effected by their care. 4. To improve the patient assessment-treatment-reevaluation process for such populations. The study sample consisted of a population of children from two institutions for the mentally retarded. The children were 12 years of age or younger and had resided at least 3 months in one of the participating institutions. Population A consisted of 236 children at the Lapeer State Home and Training School in Lapeer, Michigan. Population B consisted of 304 children at the Fort Custer State Home and Training School, Augusta, Michigan. Four methods were utilized to collect data regarding the patient and his or her care needs. The methods included: 1. Abstracting the patient’s institutional medical record. 2. Structured interviews with ward staff most familiar with the patient. 3. Complete physical examination by a pediatrician. 4. Additional diagnostic and therapeutic specialty consultations, when indicated. Because quantification of data from medical examination alone did not promise to provide a measure of change in the children’s health status over a period of time, investigators constructed an index of change in function, based on activities of daily living. The combined rating techniques of Kohn and Gordon, and Cain and Levine, plus Dinnerstein’s method of data collection by interview provided the index for this study. Findings Demographic Variables 1. Duration of stay was the only factor which differed according to race and sex. Of the study population, males and nonwhite females resided for shorter periods in residential facilities. 2. For purposes of analysis, the children were divided into three diagnostic categories: mongolism, cerebral palsy, and others. They were also classified as mildly retarded, moderately retarded, and severely or profoundly retarded. Two percent of the mongoloids were profoundly retarded, compared to 50 percent of the children with cerebral palsy. Seventy percent of the mongoloid children were mildy retarded, compared to 22 percent of the children with cerebral palsy. 3. There was an inverse relationship between severity of intellectual impairment and age at admission. Of the children admitted to a State residential facility when they were 3 years of age or younger, 68 percent were severely or profoundly retarded. 4. Although mongoloid children were usually mildly retarded, half of those residing in the institutions were admitted at age 3 or younger. Medical Conditions 1. The retarded children in these two institutions had a large number of conditions that required medical care distinct from their intellectual handicap. Twenty-nine percent had one, 25 percent had two, and 29 percent had three or more associated medical conditions. Only 18 percent had no condition warranting medical attention. 2. There was a direct relationship between the severity of a child’s intellectual deficit and the number of associated handicapping conditions. 3. Severity'of dental problems varied with the duration of stay. 4. The functioning of each child physically and socially was evaluated on a 50-point scale and was scored on levels of “low,” “moderate,” and “high.” Only 20 percent of children admitted to a residential facility under age 3 were observed to have a “high” level of functioning, whereas 54 percent admitted at age 8 or later functioned this well. 5. The child's diagnostic class was related to his functioning level. While 51 percent of mongoloid children were represented in the high functioning category, only 16 percent of those with cerebral palsy achieved a high rating. Recommendations for Health Care 1. Most of the study children were referred to one or more specialists for consultation; 26 percent received one consultation; 22 percent received two; 1 1 percent received three; 7 percent received four; and 4 percent received five consultations. Thirty percent received no consultation, however. 2. The most frequent referral (18 percent) was to a consultant psychologist for psychometric examination. 3. Some consultations provided information hitherto unknown to the institutional staff, and most produced recommendations for health care that were not already part of the child’s program. 4.,Several significant correlations were found when children received two or more specialty referrals. They were: ophthalmology with neurology, ophthalmology with orthopedics, orthopedics with neurosurgery, otology with speech, and speech with psychiatry. 5. An inverse correlation existed between the severity of retardation and the number of recommendations made for health care. 6. Although mongoloid children had proportionately less intellectual deficit, they received significantly fewer recommendatic‘ms than other children studied. Mongoloid children averaged 1.42 recommendations, compared to 1.72 recommendations for cerebral palsied children, and 2.09 recommendations for other children. 7. Children with three or more medical conditions received the most recommendations. 8. Children with low function ratings received the least recommendations. Forty percent of children with low functioning scores, as opposed to 29 percent of those with high functioning scores, received no recommendations. 9. Recommendations for health care made at admission averaged 1.73 for the youngest-aged children and 1.87 for those admitted at older ages. Changes in Functioning Twenty-four months later, the children who comprised Population B were rated again on their physical and social functioning. Changes in function were classified as slight decrease or slight increase, moderate increase, and great increase. The findings were as follows: 1. For the population as a whole, the increase in function was greater than the decrease (17 points increase and 14 points decrease). At the time of followup examination, approximately 7 percent of the 269 children who remained available for data collection achieved the highest possible score (50), in contrast to no child achieving this when first examined. 2. Fifty-nine percent of those registering a great increase in functioning were the least retarded; only 11 percent were profoundly retarded. 3. The functions of cerebral palsied children increased the least. 4. About 20 percent of the children with three or more handicapping conditions registered a great increase in functioning, while 35 percent of the group with no handicaps achieved this extent of increase. 5. There was a direct correlation between the functioning level at first examination and the change in functioning noted upon the followup 10 examination. Three-quarters of the children rated at the high function level initially had at least a moderate increase in functioning when examined the second time. A moderate increase in functioning also occurred in half of the children who had initially registered in the low function level. 6. The number of recommendations for specialty consultation was significantly associated with change in functioning. 7. No single kind of recommendation (for diagnostic tests, educational or social programs, change of medications, surgery, appliances, or devices) was more strongly associated than any other to increase in functioning. Implementation of Recommendations Variables correlated with implementation of recommendations were as follows: 1. More recommendations were implemented for male children (69 percent, compared to 31 percent for females). Investigators suggested that since this finding was not accompanied by other similar findings, “chance led to spurious significance." 2. The older the child, the more the staff disagreed with consultant recommendations. 3. The younger the child, the more frequently facilities for implementing recommendations were available. 4. More alternative procedures were substituted for recommendations made for mildly retarded children. 5. The more physical handicaps the child had, the more frequently staff disagreed with consultant recommendations, and the less often facilities were available to implement recommendations. 6. Early action focused more on children with fewest consultant recommendations, but later emphasis shifted toward those with most numerous recommendations. 7. The median duration for all recommendations to be carried out (the point at which 50 percent had a final action) was slightly over 6 months. The breakdown was as follows: 30 percent of the children took less than 6 months, for another 30 percent it was 6—9 months, for 22 percent it was 10—14 months, and for 15 percent it was 15 or more months. 8. A greater proportion of profoundly retarded children had a shorter average time for action on their recommendations than others. Children with mongolism and children with moderate function scores had the longest average duration until action was taken. 9. Medication changes and diagnostic recommendations were implemented in less than 6 months, followed by recommended reevaluations in another 6 months. But more than 25 percent of the recommendations for program changes or surgery required over 1% years to be completed. Conclusions This study reflected that although the degree of retardation of mongoloid children was rated as significantly milder, and they averaged fewer physical handicaps, they were far more likely to be admitted for institutional care before 3 years of age. This raised the question of whether cosmetic Stigmata may be almost as important as retardation in leading to admission to such institutions. This possibility was supported by the fact that cerebral palsied children (who often develop Stigmata obvious to lay people by l or 2 years of age) were also admitted at very early ages—so early that accurate assessment of intellectual capacity was not possible at the time. Less striking and less well understood, but equally important, was the older age of Negro children at time of admission. Investigators questioned whether this was accounted for by (l) delay in recognition of retardation, (2) greater tolerance for the retardate in Negro society, (3) a recent increase in access for Negroes to the public facilities for the retarded, or (4) significant racial differences in the mix of etiologic types of retardation or the accompanying conditions. The researchers noted that since these institutions are increasingly serving the young, severely retarded, and multihandicapped, the role of the medical and paramedical professions in the care of the retarded should be expanded. In the opinion of the researchers, several of the common classes of medical disorders in these children involved complications of preexisting conditions, most of which could have been prevented or reduced by prompt diagnosis and treatment, such as hydrocephalus. Attentive nursing care, physical therapy, and early and continued orthopedic supervision could have avoided or reduced the severity of most of the contractures and scoliosis. Early and intensive treatment of acute respiratory infections, combined with judicious use of surgery, could have reduced the frequency of chronic infection and hearing loss. Most dental conditions could have been prevented by a program of fluoridation, adequate oral hygiene, and maintenance dental care. Few study children required medical attention for previously unrecognized acute illness. However, there was a large unmet need for the care of chronic disease, which strongly suggested that the composition of medical care in institutions should be changed. Primary prevention of disease, planning for comprehensive and coordinated evaluation and treatment, and rehabilitation of chronic disease and handicapping conditions should be prioritized equally with care for symptoms, acute illness, and trauma. The fact that 81 percent of the study’s consultant recommendations were either carried out or intent was expressed to do so indicates that institutions are able to implement preventive and habilitative programs. The investigators pointed out that the problems of evaluating functioning changes in handicapped children have not yet been solved. The functioning outcomes among the different classes of services 12 rendered (surgery, devices, social programs, etc.) could not be distinguished. The problem that remained to be solved was that of obtaining a control group. Without it, they could not determine the placebo effect and the effects of maturation and passage of time. Therefore, the investigators recommended further research in which the experimental design includes a control group. HEALTH NEEDS AND HEALTH CARE OF CHILDREN IN DAY CARE ANN DEHUFF PETERS, M.D., Frank Porter Graham Child Development Center, Child Development Research Institute, University of North Carolina, Chapel Hill, 1969. Grant No. H—79. The Frank Porter Graham Center conducts both a demonstration project in day care for children and infants and a multidisciplinary research program in child development. The center, which opened in 1966, was caring for 31 children, ranging in age from 2 months to 5 years by 1969. The center is open 10 hours a day, 5 days a week, and offers special education and enrichment programs as well as comprehensive health and medical care, including hospitalization insurance for children whose families do not carry it. Thus, even children who are ill can attend regularly. In Contrast to other such programs of that period, the Frank Porter Graham children represent all income and educational levels and include several sibships. Children are grouped in “cottages" in a type of extended-family pattern, rather than in the traditional peer-grouping of most day care centers. Health Care and Research Research on health and health care in the demonstration day care center led the investigators to the following conclusions for further testing: I. The enriched, stimulating environment of a center staffed with a variety of affectionate, but also task~oriented adults, is associated with higher than average cognitive and social development in infants and very young children, without apparent hazard to emotional well-being. 2. 111 children can safely be cared for in the same center with those who are apparently well; there is increased risk of infection transmission compared to a nuclear family, but with appropriate training and supervision of child caretakers, backed by health personnel, the risk is minimal. 3. The care of infants and toddlers requires more staff time than the care of older children, and should not be undertaken without trained staff and appropriate caretaking policies and procedures. 4. To produce reliable data, the study of children must take place in a controlled environment. Respiratory Disease The Infectious Disease Study program in the Frank Porter Graham Center began in 1966 and has continued since that time. It is an extension of studies begun in 1962 by the Infectious Disease Laboratory of the Department of Pediatrics, North Carolina Memorial Hospital. From 1966 through April 1969, microbiological information was collected on 412 episodes of respiratory illness. Virus isolation was made in approximately 35 percent of the illnesses; three distinct ‘ outbreaks of respiratory syncytial virus occurred, and one epidemic of mumps. There were frequent isolations of other agents, including ‘ Parainfluenza viruses 1 and 3, Adenoviruses types 1, 2, and 5, and as t yet untyped enteroviruses and rhinoviruses. One important aspect of 1 these studies is the documentation of reinfection and illness following repeated exposures to a specific virus. Several instances of reinfection both with and without symptomatology were demonstrated. Comparisons with Other Care Settings A pilot study was conducted on the recognizable illness and medical care experience of infants in different care settings. Four groups of children in the Chapel Hill area participated in the study: 1. The study group consisted of seven infants admitted to the center in the winter of 1967. 2. A matched control group of seven children who received a limited amount of preventive health care but did not participate in the day care and enrichment programs. 3. A control group of 12 infants, selected from families receiving public assistance, who obtained their medical care from sources outside the center, and were evaluated at appropriate intervals by psychological and health appraisals. 4. A group comparison, consisting of 41 infants, who were enrolled in the Laboratory of Infectious Disease vaccine study and receiving care from private pediatricians. In addition to the regular testing of the center population and control infants, a cross-section sample of older children was tested during the fall of 1968 in their own homes or their day care settings. Analysis of these data indicate a superiority of the black center children over their matched controls, while the advantage of the white center group over the controls is less consistent and less striking. A public health nurse, working with the center, visited the infants of the first three groups at 2-week intervals for 10 months. Each time the nurse recorded any signs or symptoms of illness. In addition, the infants’ mothers had a checklist on which to note daily any sign of illness. At the end of the 10-month period, all medical care sources identified by families of the 26 study infants and the 41 infants in the private-practice group were contacted. Records of these medical care sources gave further data on illnesses. l4 The center children had the highest number of medical contacts (17.0 average, compared to 4.7 for the matched controls), reflecting the increased medical activity of the center during the studies of infectious diseases. The next highest frequency of medical care visits was for the older children tested in 1968 at another day care center (averaging 7.7 visits). The incidence of new symptomatic episodes averaged 9.0 for center infants, 9.7 for their matched controls, 7.4 for infants from the community, and 4.1 for infants attended by private practitioners. When compared to control infants by care settings, the frequency of symptomatic episodes was in the following order, from highest to lowest: center, other large group day care, small group day care and home with siblings more than 3 years old, home with multisiblings, and homes with siblings less than 3 years old. Children in homes with no siblings had the fewest recorded symptoms. Because of the small numbers of children monitored, the investigators could not attribute these results either to the policy of admitting ill children to the center or to increased attention to health in group care settings. For the matched control group and the control group whose families received public assistance, there was a marked discrepancy in certain illnesses between reported symptomatic experience and medical care received. This is important in light of the finding of an average of 1.2 symptoms per year of otitis media in center children, compared to an average of 0.1 and 0.2 symptoms in control groups. Investigators attribute the higher symptomology in center children to closer medical surveillance. They point out that close surveillance of children in the day care center could provide better detection of recurrent otitis and prevention of serious hearing loss. Maternal Health Diaries Compared to Nurse Observation At the end of the 10-month data collection period, the symptoms noted on the mothers' checklists agreed with the nurses’ reports less than 50 percent of the time, except for symptoms of respiratory illness. A comparison between mothers’ daily checklists and the daily morbidity check by the nurse-epidemiologist at the center showed only 20 percent agreement on any specific symptom. The investigators note that this may be attributed to the difficulty in identifying specific symptoms of illness, and that the sample population was too small for the findings to be considered definitive. Psychological Research Preliminary results of standardized testing showed that the seven study infants showed a consistent, but not marked, tendency to exceed the progress of the matched controls. No consistent differences were apparent for the center children between the Bayley Mental and Motor Scales; there was a slight tendency for the control group to perform higher on the Mental Scale. The older children consistently tended to do better on verbal-abstract tests (Stanford-Binet, WPSSl Verbal Scale, Preschool Inventory) than 15 on motoric tests (WPSSI Performance Scale, Frostig, Draw-a~Man). They also had high scores on the Leiter test. Pubficafions The following publications further describe this research: Robinson, Halbert. “A Proposed Day Care Experiment and Its Physical Plant.” In: “On Rearing Infants and Young Children in Institutions.” Children’s Bureau Research Report Number I, 1967. Robinson, Halbert B., “The Frank Porter Graham Child Development Center.” In: “Early Child Care. The New Perspectives,” Laura L. Dittmann (Ed.), Atherton, New York, 1968, pp. 302-312. Peters, Ann DeHuff. “Health Support in Day Care.” Chapter 1 l of “Day Care: Resources for Decisions,” Edith Grotbert (Ed.), OEO Pamphlet 6106-1. US. Government Printing Office, Washington, DC, June 1971. Loda, Frank A., W. Paul Glezen, Wallace A. Clyde, Jr., “Respiratory Disease in Group Day Care,” Pediatrics, 49:428-37, 1972. DEVELOPMENT OF A COMMUNITY-WIDE HEALTH INFORMATION SYSTEM TO ASSIST IN MATERNAL AND CHILD HEALTH PROGRAM PLANNING ESTELLE SIKER, M.D., M.P.H., JOHN C. DESHAIES, MA, and SAMUEL P. KORPER, M.P.H., Connecticut State Department of Health, New Haven, 1970. Grant No. H-233. The Connecticut State Department of Health and the Census Use Study of the Bureau of the Census with the support of the Children’s Bureau, DHEW, developed a Maternal and Child Health Information System for New Haven, Connecticut. The Health Information System was designed to streamline and automate the retrieval of routine statistics which are needed to plan and implement health programs. The objectives of the system were: 1. To provide maternal and child health planners and other health officials in New Haven with a description of distinct population subgroups, which could be used to set priorities in terms of service to be provided. 2. To design a model that could be used by health planners in different communities throughout the country to set priorities for services in their communities. 3. To design and test methods for acquiring, linking, and displaying data and resultant analyses of local agency records and census data. The project attempted to utilize a broad information base and still maintain maternal and child health specificity. The Health Information 16 System enables planners to look at maternal and child health in its total setting. Five sources of data were included in the Health Information System. The April 5, 1967, dress-rehearsal census conducted in New Haven provided two sources; these were summaries of the lOO-percent enumeration and the 25-percent long form census. A third source was a special-purpose health survey conducted 6 months after the special census. The fourth source was the vital records system, which consisted of birth, infant death, and fetal death records. The fifth source was obstetrical records provided by Yale-New Haven Hospital, where about two-thirds of the deliveries in New Haven take place. The special-purpose family health survey, conducted 6 months after the dress-rehearsal census, was sponsored by a Children’s Bureau grant to the Connecticut State Department of Health. The purpose of the survey was to obtain specific maternal and child health data not available from the other four data sources. lncluded were: 1. Utilization of community health resources and manpower for the surveillance of health. 2. Health status—the distribution of morbidity and extent to which normal activities of the population were impaired. 3. Childbearing expectations as a measure of potential population growth. 4. Need for and utilization of day care services. The investigators concluded from their experience with this survey that a household match between the census and a postcensus survey is inefficient and impractical. Their followup procedure showed that less than 70 percent of the households matched. The group data, however, were used. The Block Group (30) was selected as the unit for data summarization. Single blocks usually do not contain a population base sufficient to provide reliable statistics, and larger, more traditional levels of analysis (census tracts, neighborhoods, etc.) conceal a great deal of diversity (heterogeneity of population characteristics). Block groups are relatively homogeneous geographic units as described on the basis of several socioeconomic characteristics. There are, on the average, four block groups per census tract, although there may be as few as one or as many as eight. A BC usually contains between 200 and 600 households and between 500 and 1,600 persons. More than 300 data summaries resulted from correlational, factor, and multivariate analysis of the five data files. Data from 107 of the 120 block groups in New Haven were entered in the final analysis. The result was the delineation of New Haven into 26 neighborhoods, each homogeneous on a composite index describing socioeconomic class of the neighborhoods. The essential characteristics of these neighborhoods were cataloged, and profiles for each were constructed. Various methods of data presentation and display; such as computer maps, overlay maps, tabulations, etc., were utilized in order to make assessment approaches of the information useful to administrators and health planners. l7 Plans were made to expand the system to include 1970 Census data, so that trend analysis is possible, and undertake such additional specialized analyses as mental health utilization. Various programs have been established around the country, which help to demonstrate the transferability of the overall Health Information System and/or the techniques developed by the project in the course of development of the system. Overview of Analyses Undertaken by the Health Information System ' Of the 120 80s, 107 were selected for analysis, 13 block groups having been dropped because of too few observations or an insufficient population base. The purpose was not to exhaust all possible hypotheses that could be tested by the data. Rather, an attempt was made to focus on a number of specific questions which are both related to maternal and child health subject matter and can be adequately examined by available Health Information System data. Dependent variables examined included fertility rate, illegitimacy rate, low birth weight, family organization, dependency, utilization of medical and dental services for health surveillance, utilization of outpatient clinics and hospital emergency rooms, restriction of normal activity, and childbearing expectations. Fertility Rate 1. Levels of fertility were inversely correlated with block group socioeconomic status index (r=.502). This index was a composite of income levels, occupational status, completion of high school, family disorganization, and housing quality. Block groups with high levels of ‘ fertility received a disproportionate amount of public assistance (r= v .391 ). There was a tendency for high fertility areas to contain significant proportions of minority races (r=.321 ) and a disproportionate share of low birth weight babies (r=.349). 2. High rates of fertility prior to and during 1967 (as indicated by the proportion of women having three or more children) were found to be predominantly functions of socioeconomic status. 3. Receipt of welfare assistance in block groups was more closely associated with race than with levels of fertility. Illegitimacy Rate 1. High levels of illegitimacy were related to low socioeconomic status , (r=.49l ), receipt of welfare income (r=.427), past levels of high fertility (r=.310), low birth weight (r=.312), and high proportions of minority races. Illegitimacy occurred disproportionately among teenage * mothers (r=.554). There was a small but statistically significant relationship between illegitimacy and poor gestation (r=.232). l8 Low Birth Weight 1. There was a small but statistically significant relationship between socioeconomic status and low birth weight (r=.233). This relationship was reduced when statistics for race were controlled. 2. The high occurrence of low birth weight was related to high levels of fertility and illegitimacy. Family Organization 1. Normal family organization was defined as the percent of children under 18 years of age living with both parents. Areas of the city with low scores on the Normal Family Life Index were characterized by a large percentage of persons on relief (r=—.697) and by a large number of married females in the labor force (r=—.331). These areas also had high proportions of minority races and high levels of fertility and illegitimacy and low birth weight babies. . 2. Normal family life appeared to be highly correlated with utilization of health resources such as going to the dentist (r=.656) or having hospital insurance (r=.702). Normal family life was inversely related to utilizing emergency rooms and clinics (r=—.410) and the percent of the population restricted because of illness or disability (r=—.245). Dependency l. Dependency was defined, for this analysis, as (l) the percent of families receiving public assistance income, and (2) percent of females with 3 or more children. Dependency was inversely correlated with visits to the dentist (r=—.491) and having hospital insurance (r=—.375). Positive correlation was found with the percent of population reporting restriction of normal activity resulting from morbidity and disability (r= .273). 2. Areas of the city with a relatively large number of families receiving public assistance income tend to contribute disproportionately to use of hospital emergency rooms and outpatient clinics, other factors tested not withstanding. 3. Areas of the city with a high proportion of the population visiting the doctor also had a high proportion visiting the dentist. 4. Higher proportions of people were lacking dental care than medical care. Utilization of Outpatient Clinics and Hospital Emergency Rooms 1. Populations utilizing hospital emergency rooms and outpatient clinics tend to be drawn from low socioeconomic status areas of the city (r=.394). 2. The areas of the city which drew heavily on outpatient clinics and emergency rooms were characterized by such concomitants of low socioeconomic status as high levels of fertility (r=.374), high illegitimacy rates (r=.3l7) high levels of parity (r=.348), and a high proportion of the population receiving public assistance (r=.33 l ). l9 3. Utilization of hospital emergency services and nonutilization of preventive dental services appeared to be less directly related to each other than to each being closely associated with minority racial status. Restriction of Normal Activity 1. The analysis indicated a relationship between the extent of activity restriction from morbidity or disability and low socioeconomic status (r =.280). After the statistical influence of persons 65 or older was eliminated, the correlations of activity restriction with low economic status was.357; with dependency .326; and with public assistance .321. 2. Restriction of activity did not appear to be related to other socioeconomic variables like fertility or illegitimacy. Childbearing Expectation 1. Childbearing expectation was defined as the proportion of married females between the ages of 15-44 who reported that they expected to have one or more children sometime in the future. The only variable significantly associated with childbearing expectation was parity (— .356). In areas of the city where women giving birth during the survey year had a relatively great number of children, there was a tendency not to indicate an expectation of future childbearing. Publication This research has been reported in detail in “Census Use Study: Health Information System II," Report No. 12, US. Bureau of the Census, Washington, DC, 1971. MOTHERS AND CHILDREN RECEIVING PUBLIC ASSISTANCE FROM THE MIDWAY DISTRICT OFFICE DEE MORGAN KILPATRICK and EDWARD E. SCHWARTZ, Midway Project on Organization and Utilization of Public Assistance Personnel, School of Social Service Administration, University of Chicago, Chicago, Illinois, 1967. Grants N0. H-68 and 090. This study is one of the products of the Midway Project on the Organization and Utilization of Public Assistance Personnel; it analyzes the services provided to women and children receiving Aid to Dependent Families with Children (ADFC). The mothers and children who were subjects of the study were accepted for public assistance between February 1963 and March 1965 by the Midway District Office of the Cook County (Illinois) Department of Public Aid. A great majority of the 343 families studied were black 20 and two—thirds had not more than two children. In almost one-third of the cases the marriage was intact. Client change was measured by comparing the results of a baseline social study made at the time of application for public assistance (Time I) with a followup study (Time II) done 1 year later, or if the case were closed before 12 months, the followup study was made at that time. This report deals with 307 mothers whose children (numbering 736) were living with them at both times. A majority of the children (69 percent) were born in wedlock, 18 percent were in their teens, and 53 percent were under the age of 5. Information regarding adjustment of the children was obtained by the research staff of the Midway Project primarily in direct interviews with the mother and observation of the child in the home situation. Additional information was gathered from sources within the County Department of Public Aid, other social agencies; medical facilities; and the schools. Checking indicated that the information given by the mothers was reasonably valid. The Children and Their Problems Problems were classified into five broad areas: health; school-learning; school-behavior problems; other disciplinary problems; miscellaneous problems. Of the children studied, 57.5 percent had no problems at Time ll as compared with 53.0 percent at Time I; the problem decrease was largely among children with one problem. The proportion of children with multiple problems increased. This increase was mainly in the health and school-learning areas. The investigators reported that more than two of every five children in the study had a problem in one of the five classified areas. The largest group of problems at both times was behavioral problems other than those related to school. Health Problems Approximately one in every seven had a health problem. More acute problems than chronic problems were reported at both times. Respiratory conditions, which were the most frequent (about one-third) of the acute problems, were concentrated in the children under 6 years of age. The largest number of chronic problems were found in the diagnostic group which included nutritional disease. lnfective and parasitic diseases, consisting chiefly of the communicable diseases of childhood, showed the largest proportionate increase from Time I to Time II of any of the specific acute conditions. The most prevalent chronic conditions at Time I were allergenic, endocrine system, metabolic, and nutritional diseases. The second largest group of chronic conditions was mental or psycho-neurotic disorders. As a result of a decrease in diseases grouped with allergies, and an increase in mental and psycho-neurotic disorders, at Time II the rate for both of these categories was reported as 3.4. Sixteen children at Time I and 25 children at Time ll were reported in the category of mental and psycho-neurotic disorders. This represented the largest absolute increase for any of the specific conditions. However, this increase was in large part an artifact of the data collection process. While the prevalence of illness appeared to decline as the children i grew older, the total number of those with health problems was about the same at both study times. The proportion of girls in the study . * remained stable while the number of boys rose higher than the girls at J Time ll. The majority of children with health problems received care in hospital out-patient clinics. At both times of the study, dental care was the greatest additional health resource needed. The second was for basic vaccinations and innoculations, which was the greatest need for children * under 6 years. At Time II, the investigators stated that 34 percent of the children who had health problems had not received medical care. This percentage was higher than at Time I. The data raised serious questions about the coverage and adequacy of the health aspects of the Public Aid Program. The greatest improvement in medical care noted at Time II was a decrease in the need for immunizations in the under 6 age group. School Problems School status of the child was considered an important variable in evaluating the total adjustment. Of the 736 children, there were 332 in A, school at Time I and 386 at Time II. At Time I, approximately 43 percent of the children had problems at school; learning problems were most prevalent. At Time ll, 37 percent of the children had school problems chiefly due to a decrease in the number with learning problems. Initially, a larger proportion of boys than girls had school problems, but at Time ll the difference narrowed. Mothers of children with behavior problems showed more concern than mothers whose children had learning problems. In the response of mothers to their children’s problems, there was a decrease in punitive actions and an increase in positive responses. Approximately 80 percent of the mothers had contact with the schools in regard to their children’s difficulty. Discipline Problems The percentage of those who had disciplinary problems increased in succeeding age groups. Mothers reported more delinquent behavior than was officially recorded and showed great concern over what they felt was predelinquent behavior. At both times only 1 percent of the study children were alleged to have committed offenses for which they had been arrested or picked up by juvenile authorities or were under the supervision of the court during the preceding year. The most frequently alleged type of offense was truancy and curfew violations. The difference between the volume of “officially” recognized delinquent and predelinquent behavior and the perceptions and 22 concerns of the mothers about such behavior was striking. Whereas only 8 children at Time I and 10 at Time ll were officially classified as delinquent or predelinquent, 66 and 48 children respectively were regarded by their parents as engaged in behavior that was, or bordered on, delinquent. Miscellaneous Problems Problems were reported for 222 of the 736 study children at Time I and for 195 at Time [1. Although the number of children involved decreased, the number of problems reported increased slightly from 289 to 297. The most prevalent problems at both times were “slow development," “withdrawn behavior,” “bed-wetting," “sibling rivalry,” and “asthma.” Other problems were mainly complaints by mothers about their children’s passive behavior. Mothers and Their Problems The 307 mothers of the study children were predominantly young black women who were southern born. Most had some high school education and work experience which was chiefly in unskilled occupations. They had tended to marry men with less formal education than themselves—men from whom they were separated; 18.6 percent were unmarried; 28.3 percent were living with their husbands. The ability of the mothers to obtain needed medical care improved markedly from Time 1 to Time 11; approximately 38.4 percent were rated as having adequate or better medical care patterns at Time I and 56.3 percent at Time 11. Pregnancy, which was reportable as a health problem, constituted the most prevalent acute health problem for the mothers at both times. The apparent improvement in health at Time II was largely attributable to the decline in pregnancies after the women became dependent on public assistance. Excluding pregnancies from consideration, the number of maternal health problems showed a small increase. The most prevalent chronic conditions, at both times, were disease of the genito-urinary system and the circulatory system and blood-forming agencies. Seventy-six percent of the mothers had not received adequate dental care. More than three-fourths gave inadequate attention to preventive care, and almost half did not even respond to conditions requiring treatment. Pregnant Women There were 103 pregnant women in the 343 family cases studied. At Time 1, almost two-thirds (67) already had children. These women were younger, had more formal education, and their husbands had more education than the other women in the total group. However, these women were more likely to be unmarried than were the total group of mothers. 23 Of the 103 pregnant women, only 16 applied for prenatal care during their first trimester of pregnancy. The majority applied in the third trimester, almost half of whom had not received prenatal care prior to that time. Two-thirds of those who had prenatal care received it at the city’s public health clinics; most of these women were married. The major reason (37) given for not seeking medical care was reluctance to take the time from work. Many who did stated that the low quality care they received was not worth the loss of earnings involved. In 6 of the l 1 cases where employment was not a factor, the women were so psychologically disorganized that it was unlikely they would have sought prenatal care on their own. Of the remaining five cases, two had been in the city less than 6 months and were somewhat isolated; two had five or more prior pregnancies and stated that they knew how to take care of themselves; one gave no specific reason. Over half of the 97 women who had delivered by Time 11 had done so at Cook County Hospital. The investigators stated that a political decision made at that time allowed the Department of Public Aid to purchase maternity services in private hospitals on a large scale. This resulted in a larger proportion of pregnant women (31.1 percent) being admitted to delivery rooms in private hospitals than might have been under other circumstances. Six of the women were delivered at home by the Chicago Maternity Center. Almost half of the women did not have postnatal care. The characteristics of those who did seek such care were: a high school education, no previous live-born children or pregnancies, and receipt of prenatal care for this pregnancy. Diseases of the heart and circulatory system and diseases of the genito-urinary system were less prevalent among the pregnant women than in the total group of mothers. Similarly, their unmet needs for medical and dental care were somewhat lower. Nevertheless at Time 11, 24 percent of the pregnant women with health problems had received no professional help with those problems and almost half (48.5 percent) needed dental care. :2 U S. GOVERNMENT PRINTING OFFICE : 1977 241-186/1064 U.S. DEPARTMENT OF HEALTH. EDUCATION,AND WELFARE Public Health Service Health Services Administration Bureau of Community Health Services — Flockville, Maryland 20857 U.S.MAIL _ OFFICIAL BUSINESS Penalty for Private Use $300 Postage and Fees Paid U.S. Department of HEW HEW 396 ‘81"! 1» ‘ins MP} ‘Dt 0 "UV; . a Berke‘ey, DHEW Publication No. (HSA) 7775704