Many primary care physicians are not providing care that is consistent with recommendations to prevent, to identify, and to manage childhood obesity. This report presents modifications made to the electronic medical record system of a large pediatric health care system, using a quality improvement approach, to support these recommendations and office system changes. Although it is possible to make practice changes secondary to electronic medical record system enhancements, challenges to development and implementation exist. Pediatrics 2009;123:S100-S107 O VER THE PAST 3 decades, the national prevalence of overweight has tripled for children and adolescents. 1 Approximately 37% of Delaware children have a BMI of Ն85th percentile, making them overweight or obese. 2 Important psychological and medical consequences of excess weight and antecedents of adult disease occur in obese children and adolescents. In addition, obese children and adolescents are more likely to become overweight or obese adults; this concern is greatest among adolescents. 3 Childhood obesity is a complex problem that must be addressed in the multiple settings in which children spend their time. Although primary care interventions alone will not resolve the obesity epidemic, addressing this issue in the primary care setting is an important component of the overall approach to resolving this crisis. Expert recommendations for addressing childhood overweight in this setting have been in existence for a decade, 4 and new expert recommendations were released recently. 5 These recommendations include guidance for assessment of overweight, obesity, and comorbid conditions, as well as assessment and counseling on associated dietary, physical activity, and sedentary behaviors.Multiple studies have revealed that many primary care practitioners are not providing care that is consistent with these recommendations. 6-10 An example of an overused test is thyroid function testing. Although such testing is not recommended by the American Academy of Pediatrics, O'Brien et al 8 found that the majority of physicians who requested laboratory studies for the initial treatment of overweight children included thyroid function studies. Kologatla and Adams 11 found that knowledge of guidelines was not associated with adherence; although 19% of physicians were aware of the national recommendations, only 3% reported adhering to all of them.For primary care clinicians, barriers to providing the recommended care to address childhood obesity include lack of self efficacy, 12,13 inadequate tools or resources, 14,15 insufficient knowledge and skills, 12,14,16 lack of time, [11][12][13]17,18 competing priorities, 19 insufficient reimbursement, [11][12][13]19 and lack of awareness of community resources. 20 Cabana et al 21 found that self-efficacy was associated with guideline implementation. Perrin et al 22 demonstrated an association between pediatrician self-efficacy regarding obesity counseling and access to tools, especially electronic tools. In another study, phys...

In 2006, approximately 37 percent of Delaware's children were overweight or obese. To combat Delaware's childhood obesity epidemic, Nemours, a leading child health care provider, launched a statewide program to improve child health. The "social-ecological" strategy reaches beyond clinical encounters to promote better health and behavior at multiple levels. Early results show that the initiative halted the increase in the prevalence of overweight and obese children, since no statistically significant change occurred during the two-year span between administrations of the Delaware Survey on Children's Health. The initiative also spurred increased knowledge of healthy eating and awareness of the need for increased physical activity in school, child care, and primary care settings.

Objective.To compare the prevalence of contraceptive use among teenage mothers who were participating, and teenage mothers who were not participating, in a program in Jamaica that had been established to deal with the country's serious problem of repeat pregnancies among adolescents. Methods. A historical cohort design was used to assess the impact that the Women's Centre of Jamaica Foundation (WCJF) Programme for Adolescent Mothers had on contraceptive use among the target population of adolescents 16 years and under who had experienced a first live birth in 1994. Results. Contraceptive use at first intercourse was found to be higher among WCJF program participants (44%) than among nonparticipants (37%), but this difference was not significant (P = 0.35). Contraceptive use after first live birth was also higher among WCJF program participants (94%) than among nonparticipants (86%), and this difference was significant (P = 0.04). Contraceptive prevalence at last intercourse (in 1998) did not differ between participants and nonparticipants (both 69%). Conclusions. Contraceptive use among this population in

This historical cohort study investigated whether dimensions of the expanded Health Belief Model (HBM), the theoretical framework most applicable to the Women's Center Jamaica Foundation (WCJF) Program for Adolescent Mothers, can be applied to predict the occurrence of repeat pregnancies among teen mothers. A random sample ( n = 260) of primiparous Jamaican adolescent mothers 16 years and under who gave birth in 1994 in the parishes of Kingston & St. Andrew, St. Catherine, and Manchester was selected from vital records and interviewed in 1998 for this study. Multivariate analyses indicated that in addition to WCJF program participation, perceived severity, perceived susceptibility, and perceived benefits were significant ( p < .05) independent predictors of repeat pregnancy. We recommend the HBM as a useful tool to identify participants who are more likely to experience one or more repeat pregnancies.

Initiated in 1991, the Federal Healthy Start Program includes 105 community-based projects in 39 states, the District of Columbia and Puerto Rico. Healthy Start projects work collaboratively with stakeholders to ensure participants' continuity of care during pregnancy through 2 years postpartum. This evaluation of Healthy Start projects examined relationships between implementation of nine core service and system program components and improvements in birth and project outcomes. Program components and outcomes were examined using data from a 2010 Healthy Start project director (PD) survey (N = 104 projects) and 2009 performance measure data from the Maternal and Child Health Bureau Discretionary Grant Information System (N = 98 projects). We explored bivariate relationships between the nine core program components and (a) intermediate and long-term project outcomes and (b) birth outcomes. We assessed independent associations of implementation of all core program components with birth outcomes, adjusting for project characteristics and activities. In 2010, 57 projects implemented all nine core program components: 104 implemented all five core service components and 69 implemented all four core systems components. Implementation of all core program components was significantly associated with several PD-reported intermediate and long-term project outcomes, but was not associated with singleton low birth weight or infant mortality among participants' infants. This evaluation revealed a mixed set of relationships between Healthy Start projects' implementation of the core program components and achievement of project outcomes. Although the findings demonstrated a positive impact of Healthy Start projects on birth outcomes, only a few associations were statistically significant.