A case study of the effects of privatization of child welfare on services for children and families: The Nebraska experience

Privatization, or contracting with non-governmental agencies for provision of state or federally funded services, is a strategy that has gained recent attention from policymakers as a potential tool for successful child welfare reform. The Child Welfare Privatization Initiatives Project was created in 2007 as a joint effort between the United States Department of Health and Human Services and the Office of the Assistant Secretary for Planning and Evaluation. The framework identified by this project produced twelve key considerations for states moving towards a privatized system. This case study considers these twelve considerations in a description of the large-scale effort to privatize child welfare services in the state of Nebraska that began in 2008. Problems leading to a need for child welfare reform and possible factors that motivated policymakers to shift services from the public to the private sector are also described. While proponents of privatization appeared to expect rapid increased efficiency and cost-savings, this case study explores multiple reductions in quality and availability of services for children and families served by the child welfare system that occurred during the effort. Further, the cost of child welfare services in Nebraska increased by 27% and the private agencies invested over $21 million of their own funds as they attempted to uphold contracts. Recommendations for practitioners and policymakers considering participating in efforts to privatize child welfare services in the future are made based on Nebraska’s recent experience

Understanding Perceptions of Child Maltreatment Risk: A Qualitative Study of Early Head Start Home Visitors

Infants and toddlers enrolled in Early Head Start are at increased risk for child maltreatment. Within Early Head Start, home visitors are in a unique position to identify the families most likely to experience maltreatment by identifying characteristics and behaviors of children, caregivers, families, and environments that are of concern. However, research has demonstrated that home visitors are often ill-equipped to identify and address risk factors such as parental mental health concerns, substance abuse, and domestic violence. Further, little is known about how home visitors understand and perceive risk for maltreatment and identify vulnerable families. The study sought to identify how Early Head Start home visitors understand maltreatment, perceive risk for maltreatment, and work with families identified as at-risk. Qualitative interviews exploring identification of risk for maltreatment were conducted with fourteen Early Head Start home visitors and supervisors. Results indicate variable understanding of maltreatment. Home visitors identified numerous factors they believe suggest elevated risk for maltreatment and described variable approaches to working with families at risk. Findings provide rich information about the role that home visitors play in maltreatment prevention within Early Head Start. Directions for effectively training home visitors to engage families and deliver program and community-based services in a manner that reduces risk for and prevents maltreatment are discussed

Increasing Participation and Improving Engagement in Home Visitation: A Qualitative Study of Early Head Start Parent Perspectives

Home visitation programs are designed to provide comprehensive services that promote parents’ abilities to create stable, nurturing care environments for their children. In order for program goals to be met, parents must participate actively and be engaged with the programs’ mission. However, promoting engagement and participation are complex processes that have been understudied in research on home visitation. The current qualitative study examined how a national, federally funded home visitation program, Early Head Start (EHS), engaged and retained families so that potentially helpful preventative interventions could be delivered. The study also identified barriers to active engagement. Semistructured interviews were conducted with 10 parents of children enrolled in EHS. Findings suggest that engagement increased when EHS reduced social isolation by forming connections among parents and when the program focused on involving parents in fostering their children’s meeting of important developmental milestones. Barriers to engagement identified included logistical and organizational challenges as well as parental biases and differences in values and attitudes. Practice and policy recommendations for improving EHS and other programs that serve similar populations to increase engagement are discussed

Physiological Correlates of Volunteering

We review research on physiological correlates of volunteering, a neglected but promising research field. Some of these correlates seem to be causal factors influencing volunteering. Volunteers tend to have better physical health, both self-reported and expert-assessed, better mental health, and perform better on cognitive tasks. Research thus far has rarely examined neurological, neurochemical, hormonal, and genetic correlates of volunteering to any significant extent, especially controlling for other factors as potential confounds. Evolutionary theory and behavioral genetic research suggest the importance of such physiological factors in humans. Basically, many aspects of social relationships and social activities have effects on health (e.g., Newman and Roberts 2013; Uchino 2004), as the widely used biopsychosocial (BPS) model suggests (Institute of Medicine 2001). Studies of formal volunteering (FV), charitable giving, and altruistic behavior suggest that physiological characteristics are related to volunteering, including specific genes (such as oxytocin receptor [OXTR] genes, Arginine vasopressin receptor [AVPR] genes, dopamine D4 receptor [DRD4] genes, and 5-HTTLPR). We recommend that future research on physiological factors be extended to non-Western populations, focusing specifically on volunteering, and differentiating between different forms and types of volunteering and civic participation

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background: Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods: For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings: Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation: Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life

Reducing the Clinical and Public Health Burden of Familial Hypercholesterolemia A Global Call to Action

Q1Q1Artículo completoE1-E13IMPORTANCE Familial hypercholesterolemia (FH) is an underdiagnosed and undertreated genetic disorder that leads to premature morbidity and mortality due to atherosclerotic cardiovascular disease. Familial hypercholesterolemia affects 1 in 200 to 250 people around the world of every race and ethnicity. The lack of general awareness of FH among the public and medical community has resulted in only 10% of the FH population being diagnosed and adequately treated. The World Health Organization recognized FH as a public health priority in 1998 during a consultation meeting in Geneva, Switzerland. The World Health Organization report highlighted 11 recommendations to address FH worldwide, from diagnosis and treatment to family screening and education. Research since the 1998 report has increased understanding and awareness of FH, particularly in specialty areas, such as cardiology and lipidology. However, in the past 20 years, there has been little progress in implementing the 11 recommendations to prevent premature atherosclerotic cardiovascular disease in an entire generation of families with FH. OBSERVATIONS In 2018, the Familial Hypercholesterolemia Foundation and the World Heart Federation convened the international FH community to update the 11 recommendations. Two meetings were held: one at the 2018 FH Foundation Global Summit and the other during the 2018 World Congress of Cardiology and Cardiovascular Health. Each meeting served as a platform for the FH community to examine the original recommendations, assess the gaps, and provide commentary on the revised recommendations. The Global Call to Action on Familial Hypercholesterolemia thus represents individuals with FH, advocacy leaders, scientific experts, policy makers, and the original authors of the 1998 World Health Organization report. Attendees from 40 countries brought perspectives on FH from low-, middle-, and high-income regions. Tables listing country-specific government support for FH care, existing country-specific and international FH scientific statements and guidelines, country-specific and international FH registries, and known FH advocacy organizations around the world were created. CONCLUSIONS AND RELEVANCE By adopting the 9 updated public policy recommendations created for this document, covering awareness; advocacy; screening, testing, and diagnosis; treatment; family-based care; registries; research; and cost and value, individual countries have the opportunity to prevent atherosclerotic heart disease in their citizens carrying a gene associated with FH and, likely, all those with severe hypercholesterolemia as well

A case study of the effects of privatization of child welfare on services for children and families: The Nebraska experience

Privatization, or contracting with non-governmental agencies for provision of state or federally funded services, is a strategy that has gained recent attention from policymakers as a potential tool for successful child welfare reform. The Child Welfare Privatization Initiatives Project was created in 2007 as a joint effort between the United States Department of Health and Human Services and the Office of the Assistant Secretary for Planning and Evaluation. The framework identified by this project produced twelve key considerations for states moving towards a privatized system. This case study considers these twelve considerations in a description of the large-scale effort to privatize child welfare services in the state of Nebraska that began in 2008. Problems leading to a need for child welfare reform and possible factors that motivated policymakers to shift services from the public to the private sector are also described. While proponents of privatization appeared to expect rapid increased efficiency and cost-savings, this case study explores multiple reductions in quality and availability of services for children and families served by the child welfare system that occurred during the effort. Further, the cost of child welfare services in Nebraska increased by 27% and the private agencies invested over $21 million of their own funds as they attempted to uphold contracts. Recommendations for practitioners and policymakers considering participating in efforts to privatize child welfare services in the future are made based on Nebraska’s recent experience

Early Head Start service use by families with court-substantiated maltreatment

Early Head Start (EHS) is an evidence-based intervention program for at-risk children birth through three that seeks to improve child and family well-being. There is little research to date examining the prevalence of child maltreatment among families enrolled in EHS and the extent to which maltreatment is associated with receipt of programs and services available to EHS families. This study sought to (a) identify the prevalence of court substantiated maltreatment in EHS families; and (b) determine the association between substantiated maltreatment and use of EHS program and community-linked services. To answer these questions, archival program and clinical service records and juvenile court records on 743 EHS families were extracted and analyzed. Negative binomial and logistic regression models examined the relationship between court-substantiated maltreatment and use of program and community-linked services. Overall, 14.9% of enrolled families had a court substantiated case of maltreatment. Presence of a maltreatment record was differentially associated with use of program services, including overall number of home visits (β=−0.16, p=0.014, 95% CI [−0.28,−0.03]) and receipt of Child Abuse Prevention Services (OR = 7.21, 95% CI [3.21, 16.21]), Domestic Violence Assistance (OR = 5.88, 95% CI [2.55, 13.53]), and English as a Second Language (OR = 0.26, 95% CI [0.11, 0.63]. Children and families served by EHS experience maltreatment at higher rates than the general population. There is a need to develop strategies to explicitly target families who experience child maltreatment. Implications for serving and engaging high-risk families in EHS are discussed

Understanding Perceptions of Child Maltreatment Risk: A Qualitative Study of Early Head Start Home Visitors

Infants and toddlers enrolled in Early Head Start are at increased risk for child maltreatment. Within Early Head Start, home visitors are in a unique position to identify the families most likely to experience maltreatment by identifying characteristics and behaviors of children, caregivers, families, and environments that are of concern. However, research has demonstrated that home visitors are often ill-equipped to identify and address risk factors such as parental mental health concerns, substance abuse, and domestic violence. Further, little is known about how home visitors understand and perceive risk for maltreatment and identify vulnerable families. The study sought to identify how Early Head Start home visitors understand maltreatment, perceive risk for maltreatment, and work with families identified as at-risk. Qualitative interviews exploring identification of risk for maltreatment were conducted with fourteen Early Head Start home visitors and supervisors. Results indicate variable understanding of maltreatment. Home visitors identified numerous factors they believe suggest elevated risk for maltreatment and described variable approaches to working with families at risk. Findings provide rich information about the role that home visitors play in maltreatment prevention within Early Head Start. Directions for effectively training home visitors to engage families and deliver program and community-based services in a manner that reduces risk for and prevents maltreatment are discussed