*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing 1904-1997

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any comments contact Steve Holve, MD, Chief
Clinical Consultant in Pediatrics at sholve@tcimc.ihs.gov

IHS Child Health Notes

December 2006

# Quote of the month

*\"I\'ve had a perfectly wonderful evening.  But this wasn\'t it.\"*

Groucho Marx

**Article of Interest**

Diagnosis and management of bronchiolitis.\
Pediatrics. 2006 Oct;118(4):1774-93.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed>

Lower respiratory tract infections among American Indian and Alaska
Native children and the general population of U.S. Children. Pediatr
Infect Dis J. 2005 Apr;24(4):342-51.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed>

Editorial Comment

By the time you read this it may already be too late.

Respiratory season will begin sometime in December and resolve by March.
Each year hospitals and clinics are swamped with wheezing and coughing
infants. Dr. Singleton's article demonstrates what we all have felt each
winter: the burden of respiratory illnesses is greater for AI/AN
children than the general US population.

The bronchiolitis guidelines in *Pediatrics* are an evidenced based
summary of what we know and what works. The bottom line is that usually
"less is more". Less tests, less radiographs, less oximeters, less
antibiotics and less nebulizer treatments would benefit our patients.
More clinical judgment would help to decide whom to admit and whom to
discharge. Read both articles as you get ready for the onslaught of
winter.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

**Does in-home water service reduce the risk of infectious disease?**

A cornerstone of health improvements in the United States during the
past century has been modern sanitation services, such as safe drinking
water and wastewater disposal services. Nowhere has the effort to bring
sanitation to homes been the more difficult than in remote Alaska
villages. In 2000, only 77% of Alaskan homes had in-home running water
and flush toilets. We compared disease rates from the IHS/tribal
hospital discharge data for Alaska Natives (fiscal years 2000-2004) by
the water service level as determined from the Rural Alaska Housing
Sanitation Inventory (July 2002 -- April 2004). Hospitalization rates
were substantially higher in low service regions compared those in high
service regions for RSV (risk ratio \[RR\] 3.4, 95% confidence interval
\[CI\] 2.95-3.8), pneumonia/influenza (RR 2.5, 95% CI 2.4-2.7), skin
infection (RR1.9, 95% CI 1.8-2.1), and MRSA infection (RR 4.5, 95% CI
3.6-5.7). Hospitalization rates for infectious diarrhea did not differ
significantly with availability of in-home water service.

Safe drinking water (available to all Alaskan communities) may be the
intervention of greatest significance for control of diarrheal disease.
However, for respiratory and skin infections, where hygienic measures
such as hand washing are important means for preventing person-to-person
spread, lack of piped in-home water service likely contributes to
transmission of disease.

Acknowledgements: This data was developed by Tom Hennessy MD, Arctic
Investigations Program, Centers for Disease Control and Prevention,
Anchorage, AK; Troy Ritter, MPH, Environmental Health Consultant, Alaska
Native Tribal Health Consortium, and Robert Holman MS, DVRD, Centers for
Disease Control and Prevention, Atlanta.

**Recent literature on American Indian/Alaskan Native Health**

Doug Esposito, MD

**[Article]{.underline}**

Home-visiting intervention to improve child care among American Indian
adolescent mothers: a randomized trial. *Arch Pediatr Adolesc Med*. 2006
Nov;160(11):1101-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17088511&query_hl=1&itool=pubmed_DocSum>

**Summary**

The authors report the short-term impact of a paraprofessional-delivered
home-visitation program targeting Navajo and White Mountain Apache teen
mothers. The primary outcomes investigated are maternal knowledge,
skills, and involvement in childcare. Also assessed are several
secondary outcomes that pertain to psychological and behavioral risks
that could negatively influence successful child rearing (family
conflict and cohesion, social support, self esteem, locus of control,
and drug use).

Enrolled participants were randomized to intervention or control groups.
The family-strengthening home-visitation intervention was modeled after
"Healthy Families America"
(<http://www.healthyfamiliesamerica.org/network_resources/training.shtml>).
The content of the intervention curriculum was based on the *AAP Guide
to Baby Care: Caring for your Baby and Young Child: Birth to Age 5* and
information contributed by the community regarding what teen moms needed
to know to be successful parents. Twenty five home visits lasting about
1.5 hours each were scheduled during which 41 lessons were presented,
starting at 28 weeks gestation and ending six months post-partook. The
control group was provided with breastfeeding education only. Twenty
three visits lasting about 1 to 1.5 hours each were scheduled during
which 20 breastfeeding lessons were taught. The educational content of
both the intervention group and the control group was made culturally
relevant.

The educators were bilingual, highly-trained, well-supervised American
Indian women from the community. All were either former teen mothers or
had a demonstrated interest in the target population. Outcomes were
assessed through self-reports and knowledge/skills tests administered at
baseline (≤28 weeks gestation) and at two and six months post-partook.

The authors state that "this is the first published randomized trial
assessing the impact of a family-strengthening home-visiting
intervention on American Indian pregnant teens as a target population."
The only outcome found to be significantly different between
intervention and control groups was a higher average knowledge score at
two and six months post-partook in the intervention group. The authors
state that although not proven, increased knowledge in mothers could
lead to increased effectiveness in parenting, and better outcomes. The
intervention group may also have reduced depression risk, but this could
not be definitively concluded due to study limitations.

Fortunately, a larger more comprehensive randomized controlled trial of
this intervention is currently underway. Hopefully, we will soon know
more definitively if this paraprofessional-delivered
family-strengthening home visiting model is an effective way to improve
the health and health behaviors of American Indian teen mothers and
their children.

**Editorial Comment**

Nurse-delivered home-visiting interventions, though proven effective,
are resource and time intensive. In the Olds interventions (see links
listed below) one nurse typically followed approximately 25 families,
with services being delivered to each family for two years. Although
wonderful and necessary programs, it is unlikely that the IHS could
integrate such a model into its system of prevention in a sustainable
manner given current budgetary restrictions, the status of the national
nursing shortage, and Agency-specific difficulties in recruitment and
retention of qualified nurse professionals. Paraprofessional-delivered
home-visiting interventions hold promise as a more cost-effective
alternative to these nurse-delivered interventions, if ultimately proven
effective.

Although a Public Health Nurse (PHN) is uniquely qualified to deliver
population-based preventive health services out in the community, these
valuable skills are often untapped in the IHS. PHN time and energy is
typically diverted away from public health practice and focused more on
the provision of direct medical care in the field, typically functioning
as an extension of clinical or hospital care. In their current practice
environment, the IHS PHN might be more aptly titled "Field Health
Nurse;" sort of a jack-of-all-trades in the out-of-hospital setting! In
my opinion, this is an inefficient use of their specialized skill-set
and represents a situation in desperate need of attention.

Over the last several decades, we have witnessed a dramatic
transformation in the nature of the health problems facing Native
Americans. Preventable chronic diseases, injuries (both intentional and
unintentional), and behavior-related maladies have replaced acute
infectious diseases as the most pressing health problems facing AI/AN
populations and their health systems. Much more community-based public
health prevention is needed in the IHS if we ever hope to stem the tide
of this concerning trend in chronic disease.

Over the same timeframe, we have seen an explosion in the complexity of
medical diagnostics and therapeutics, demanding a reflexive increase in
the specialization of clinical services. Although still a little behind,
the IHS has generally been able to keep pace with advances in medical
care that are delivered within the confines of its hospitals and
clinics. A true study in thrift! Unfortunately, the same cannot be said
of clinical nursing services delivered in the field, especially in rural
IHS settings where developed systems of home health are essentially
nonexistent. Although not their forte, PHN Departments struggle to meet
this demand, further taxing their capacity to provide much-needed
preventive public health services.

I believe it is time for the IHS to completely rethink and reengineer
its Public Health Nursing Program. "Field Health" is begging to be
divided into two corps of highly skilled nurse professionals; Home
Health Nursing and Public Health Nursing. Such a change would allow for
the provision of skilled nursing care outside of the clinic or hospital
setting while simultaneously providing an opportunity for the PHN to
focus on public health practice and prevention and the development of a
more robust public health infrastructure.

If you are finding yourself wondering how the heck this all relates to
the subject at hand (paraprofessional-delivered home-visiting
interventions, remember?), please read on!

As previously stated, the mere expansion of PHN duties and functions to
accommodate the implementation of targeted home-visiting interventions
is not currently feasible (you know, funding, nursing shortages, etc.).
However, if the above restructuring were to occur, I believe that
community health programs could be organized into coordinated,
comprehensive Community Health Teams. These teams would consist of a
PHN, a Home Health Nurse, and a variety of specifically trained
paraprofessionals. These teams would have the capacity to deliver
services and programs designed to meet the defined needs of individual
populations and communities. Suicide prevention, pedestrian and motor
vehicle occupant safety, diabetes, adolescent pregnancy, whatever the
community would choose to target as its biggest problems, would be fair
game. And, the home health services and field medical care would be
expertly delivered, too! Perhaps Social Workers, Mental Health Workers,
Nurse Practitioners, and even physicians could be integrated into this
system for added breadth and functionality.

The authors of the study under review give us hope that a new
evidence-based approach utilizing paraprofessionals might be on the
horizon as a viable option within our Indian Health System. If
ultimately shown to be an effective model, will the IHS be able to
create something truly innovative and perhaps even revolutionary? Our
50-year history is marked by extraordinary achievement, even against the
greatest of technical and political odds. The IHS has a long and storied
history of innovation; one that I anticipate will endure the challenges
of our times.

**Additional Reading**

Home visiting by paraprofessionals and by nurses: a randomized,
controlled trial. *Pediatrics*. 2002 Sep;110(3):486-96.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12205249&query_hl=8&itool=pubmed_docsum>

Effects of home visits by paraprofessionals and by nurses: age 4
follow-up results of a randomized trial. *Pediatrics*. 2004
Dec;114(6):1560-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15574615&query_hl=8&itool=pubmed_docsum>

**[Article]{.underline}**

Forty years in partnership: the American Academy of Pediatrics and the
Indian Health Service. *Pediatrics*. 2006 Oct;118(4):e1257-63.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17015514&query_hl=1&itool=pubmed_DocSum>

**Editorial Comment**

This article is "required reading" for all healthcare worker interacting
with American Indian/Alaska Native children! Unfortunately, it is
concealed within the "e-pages" of the October issue of *Pediatrics*. I
highly recommend each and every one of you click on the link and read
this important paper chronicling the 40+ year history of commitment,
contribution, and collaboration between the AAP and the Indian Health
Service, Tribal, and urban health programs in the advancement of the
health status of one of this country's most vulnerable yet resilient
populations! Of course, we still have a ways to go. But then, isn't that
why we're all here?

**Locums Tenens and Job Opportunities**

If you have a short or long term opportunity in an IHS, Tribal or Urban
facility that you'd like for us to publicize (i.e. AAP Web site or
complimentary ad on Ped Jobs, the official AAP on-line job board),
please forward the information to <indianhealth@aap.org> or complete the
on-line locum tenens form at <http://www.aap.org/nach/locumtenens.htm>

.