Who Is Caring for Health Care Workers' Families Amid COVID-19?

Amid the COVID-19 pandemic, women in medicine, including faculty, residents, medical students, and other health care workers (HCWs), are facing unparalleled challenges. The burdens of pandemic-associated increases in domestic and caregiving responsibilities, professional demands, health risks associated with contracting COVID-19, and the resulting psychosocial distress have exacerbated existing gender disparities at home, at work, and in academia. School and day care closures have created additional childcare needs, primarily for women, yet little support exists for parents and families. These increased childcare and domestic responsibilities have forced women HCWs, who make up the overwhelming majority of the workforce, to adapt their schedules and, in some cases, leave their jobs entirely. In this article, the authors detail how COVID-19 has exacerbated existing childcare accessibility and affordability issues as well as gender disparities. They argue that unless government and health care organization support for childcare increases, families, specifically women and children, will continue to suffer. Lack of access to affordable childcare can prevent HCWs from doing their jobs, including conducting and publishing academic scholarship. This poses incalculable risks to families, science, and society. COVID-19 should serve as a call to action to all sectors, including the government and health care organizations, to prioritize childcare provision and increase support for women HCWs, both now during the pandemic and going forward.

Early Childhood Obesity Prevention: Challenges and Barriers of Implementing Child and Adult Care Food

INTRODUCTION

The Child and Adult Care Food Program requirements promote healthy eating behaviors and increased physical activity in the daycare setting to help prevent childhood obesity. Some of these standards can be difficult to meet for early childhood education centers. This study examines the challenges and barriers daycare centers face when implementing these guidelines.

METHODS

Focus groups consisting of participants from early childhood education centers within our community were conducted in April and May of 2018.

RESULTS

Three focus groups were conducted, with a total of 7 childcare center directors. Eight themes that affect nutrition and physical activity curriculums at early childhood education centers arose: teacher philosophy and involvement, training/expertise of staff, parental involvement, financial constraints, children's interests, food availability, physical environment, and regulations/guidelines. Overall, participants expressed their sense that child care facilities are undervalued. They agreed that healthy, fresh food choices are expensive, difficult to obtain due to the volume needed, and require additional training to prepare. Emphasis on gross motor development has a varied level of support from families and teachers. Challenges and barriers to providing adequate gross motor activities include limited financial support, lack of physical space, lack of teacher willingness to engage in outdoor activity, and parental resistance.

CONCLUSIONS

Financial constraints and the "undervaluing" of childcare contribute greatly to many of the challenges and barriers early childhood education centers face in meeting nutrition and physical activity standards. Findings from this study shed light on the significant role early childcare centers play in nurturing child development and the efforts these centers undertake in the interest of children.

Food Purchasing and Preparation at Child Day Care Centers Participating in the Child and Adult Care Food Program in the United States, 2017

BACKGROUND

More than 3.6 million children are served daily by the Child and Adult Care Food Program (CACFP)-participating child day care centers. This study provides a nationwide assessment of center-level responsibilities for menu, meal/snack preparation, meal preparer training, and food and beverage (F&B) purchasing.

METHODS

A nationally representative survey of 5483 CACFP child day care centers was conducted between August 22, 2017, and September 30, 2017. One thousand three hundred forty-three centers (25% response) in 47 states and the District of Columbia responded. Descriptive statistics describe center-level menu, meal, and purchasing practices and center characteristics. Multivariate logistic regressions examined characteristics associated with F&B purchasing sources.

RESULTS

Menus were primarily prepared by directors/assistant directors and on-site food manager/cooks, while site staff primarily prepared meals/snacks. Fifty-two percent of meal preparers held a food sanitation license, but only 5% had formal nutrition training (e.g., Registered Dietician). Most centers purchased F&B from food service providers (63%), local grocery stores (59%), warehouse stores (40%), or from 2+ sources (50%). Independent centers were more likely to purchase F&B from local grocery stores or 2+, while free or state-subsidized sites were more likely to purchase from a food service provider and less likely to purchase from other sources than were centers charging between $101 and $201.99 per week. Centers where an on-site cook/food manager prepared the menus were significantly more likely to purchase their F&B from local grocery and/or warehouse stores and/or from 2+ sources.

CONCLUSIONS

Opportunities exist to target CACFP training to specific roles within and specific types of CACFP-participating child day care centers to facilitate compliance with the updated CACFP standards.

Barriers and Facilitators to Compliance with a State Healthy Eating Policy in Early Care and Education Centers

BACKGROUND

Early care and education (ECE) policies can improve childhood obesity risk factors. We evaluated barriers and facilitators to implementing mandatory nutrition standards for foods provided in South Carolina ECE centers serving low-income children, comparing centers participating in the Child and Adult Care Food Program (CACFP) with non-CACFP centers.

METHODS

We mailed 261 surveys (demographics, policies and practices, barriers and facilitators) to center directors after new state nutrition standards were implemented in South Carolina. We conducted univariate and bivariate analyses to explore relationships between barriers, facilitators, and center-level characteristics, by CACFP status.

RESULTS

We received 163 surveys (62% response rate). Centers had a median [interquartile range (IQR)] of 5 (4-7) classrooms and 59 (37.5-89) total children enrolled. More than half (60.1%) of directors reported they were moderately or fully informed about the standards. The most common barriers were food costs (17.8%) and children's food preferences (17.8%). More non-CACFP directors reported food costs as a barrier (28.6% vs. 6.5%, p < 0.001), having to spend additional money on healthier foods (48.8% vs. 28.6%, p = 0.01), and having to provide additional nutrition education to parents (28.6% vs. 11.7%, p = 0.01), compared with CACFP directors.

CONCLUSIONS

Center directors were generally well informed about the nutrition standards. The most common barriers to implementing the standards were food costs and children's food preferences. Centers participating in CACFP may be in a better position to adhere to new state nutrition standards, as they receive some federal reimbursement for serving healthy foods and may be more accustomed to regulation.

Factors Influencing the Food Purchases of Early Care and Education Providers

BACKGROUND

With the majority of US children enrolled in some form of early care and education, the settings for early care and education represent a valuable opportunity to positively impact young children's diets and their interactions with food. Little evidence exists on how early care and education providers make food purchasing and service decisions for this population of young children.

OBJECTIVE

Our aim was to explore the factors that influence early care and education providers' food purchasing and service decisions.

DESIGN

A qualitative design consisting of individual, in-person, and semi-structured interviews with providers and on-site observations was used.

PARTICIPANTS/SETTING

Sixteen early care and education providers-selected across a variety of characteristics that might affect food selection (eg, size of site, participation in reimbursement programs, presence of staff assigned to foodservice) using maximum variation purposive sampling-based in the Puget Sound region, Washington, were interviewed from June to September 2014.

MAIN OUTCOME MEASURE

Provider perspectives on food purchasing and service decisions.

STATISTICAL ANALYSES PERFORMED

Inductive analysis of transcribed interviews using TAMS Analyzer software (GPL version 2, 2012) to identify themes.

RESULTS

Ten main influencers emerged from the data. These were grouped into four categories based on an ecological framework: macro-level environments (ie, regulations; suppliers and vendors, including stores); physical environment and settings (ie, organizational mission, budget, and structure; the facility itself); social environments (ie, professional networks; peers; the site-specific parent and child community); and individual factors at both a provider and child-level (ie, providers' skills, behaviors, motivations, attitudes, knowledge, and values; child food preferences; and, child allergies). A model was then developed to identify potential pathways of intervention and underscore the need for a comprehensive approach to improve early care and education nutrition.

CONCLUSIONS

This study suggests that a more system-based understanding and approach-one that accounts for an array of influencers and their interactions-is necessary to take advantage of opportunities and address barriers to improving early care and education-based nutrition.

Physical activity-related and weather-related practices of child care centers from 2 states

BACKGROUND

Young children's physical activity (PA) is influenced by their child care environment. This study assessed PA practices in centers from Massachusetts (MA) and Rhode Island (RI), compared them to best practice recommendations, and assessed differences between states and center profit status. We also assessed weather-related practices.

METHODS

Sixty percent of MA and 54% of RI directors returned a survey, for a total of 254. Recommendations were 1) daily outdoor play, 2) providing outdoor play area, 3) limiting fixed play structures, 4) variety of portable play equipment, and 5) providing indoor play area. We fit multivariable linear regression models to examine adjusted associations between state, profit status, PA, and weather-related practices.

RESULTS

MA did not differ from RI in meeting PA recommendations (β = 0.03; 0.15, 0.21; P = .72), but MA centers scored higher on weather-related practices (β = 0.47; 0.16, 0.79; P = .004). For-profit centers had lower PA scores compared with nonprofits (β = -0.20; 95% CI: -0.38, -0.02; P = .03), but they did not differ for weather (β = 0.12; -0.19, 0.44; P = .44).

CONCLUSIONS

More MA centers allowed children outside in light rain or snow. For-profit centers had more equipment—both fixed and portable. Results from this study may help inform interventions to increase PA in children.

Stratified familialism: the care regime in India through the lens of childcare

This article explores the political and social economy of care in India through a focus on childcare practices, from the viewpoint of the care giver — a perspective frequently ignored or touched on only generally in earlier discussions on development or social policy. It is argued that the care regime is an ad hoc summation of informal, stratified practices. It is shaped by the institutional context, in particular the economic and social inequalities of work and livelihoods, as well as trends and absences in state economic and social policy. Central to the dynamics of care practices in India is the ideology of gendered familialism in public discourse and policy, which reiterates care as a familial and female responsibility and works to devalue and diminish the dimensions of care. By delineating the range of institutions through which everyday childcare practices are organized, this contribution draws out the differentiations and actualities of stratified familialism and care. At one end of the spectrum are those who have the possibility to retain familial carers at home and supplement them with paid and other institutional carers; at the other are those who are neither able to retain family members at home nor fill the care gap through formal institutions.

A widening gap? The political and social organization of childcare in Argentina

This article examines how social policies and programmes implemented in Argentina shape the political and social organization of childcare. The author seeks to analyse how welfare institutions are currently responding to emerging needs, and to what extent they facilitate the defamilialization of childcare for different social classes. Because Argentina lacks a truly unified ‘care policy’, four different kinds of facilities and programmes are examined: employment-based childcare services; pre-school schemes; social assistance care services; and poverty reduction strategies. It is argued that far from offering equal rights and services with a universalist cast, these ‘caring’ institutions reflect the ethos of the current welfare model in Argentina: a fragmented set of social policies based on different assumptions for different social groups, which in turn filter down to the social organization of childcare.

Putting two and two together? Early childhood education, mothers’ employment and care service expansion in Chile and Mexico

In recent years, several middle-income countries, including Chile, Mexico and Uruguay, have increased the availability of early childhood education and care (ECEC) services. These developments have received little scholarly attention so far, resulting in the (surely unintended) impression that Latin American social policy is tied to a familialist track, when in reality national and regional trends are more varied and complex. This article looks at recent efforts to expand ECEC services in Chile and Mexico. In spite of similar concerns over low female labour force participation and child welfare, the approaches of the two countries to service expansion have differed significantly. While the Mexican programme aims to kick-start and subsidize home- and community-based care provision, with a training component for childminders, the Chilean programme emphasizes the expansion of professional ECEC services provided in public institutions. By comparing the two programmes, this article shows that differences in policy design have important implications in terms of the opportunities the programmes are able to create for women and children from low-income families, and in terms of the programmes’ impacts on gender and class inequalities. It also ventures some hypotheses about why the two countries may have chosen such different routes.

Liminal cultural work in family childcare: Latino immigrant family childcare providers and bicultural childrearing in the United States, 2002-2004

Immigrants find themselves in a liminal state of limbo between two societies. In this zone, competing cultural ideas coexist. This essay examines how Latino immigrant family childcare providers in the United States questioned US norms of childrearing and how they engaged in liminal cultural work to produce a bicultural childrearing. They are exposed to US norms through family childcare certification programmes that they were legally required to participate in, in order to receive the accreditation required to care for young children in their homes. They were simultaneously critical and embracing of US mainstream ideas of childrearing. Two contested areas for them are the emphasis on individual child development and the levelling of authority relations between adults and children. Their traditional values are absent from the training programmes, yet they develop a process of selective adaptation which both maintains and discards traditional ideas of childrearing and integrates them with some of the new ideas they learn in the US. The liminal cultural work that immigrant family childcare workers do is both for themselves and for the children and the families for whom they provide care. The providers experience a process of ongoing liminal cultural work.

[Disguises, invisibility and disqualification of the guards of children in French-speaking Switzerland]

Various factors oblige today's parents to entrust their children to a child-care worker (CCW), providing services in the domestic sphere, either at the child's parental house or at the day-care worker's (DCW's) own home. Taking this into account, this paper examines job offers and applications for DCWs published in a regional Swiss newspaper as well as other job offers and applications published on a website called bestnounou.ch. The parents often tend to use a variety of terms, which do not point to the child-caring or rearing activity itself, but rather emphasise sociological characteristics of the CCW (age, gender, civil status), requesting, for example, a “lady”, a “grandmother”, a “student”. Thereby, the parents present the child-care work as: (1) a secondary and temporary activity in relation to another major stable activity (motherhood, apprenticeship, retirement); and (2) an activity that does not require professional skills but inborn aptitudes. Moreover, employers use as synonyms distinctive terms, which refer to various categories of CCW and domestic workers, whose schedules of conditions and salaries are regulated and differ. The parents' inclination to use terms designating the most precarious and underpaid CCW underscores the importance of child-care in the domestic sphere. It leads also to a public image of child-care workers as being a fragmented, unstable, little qualified and economically inconsistent workforce, in contrast to the stable and structural need for their specific services, allowing parents to face their familial and professional responsibilities.

Quality improvements in the early care and education workforce: outcomes and impact of the T.E.A.C.H. Early Childhood Project

To date there has not been a systematic, longitudinal research to assess the efficacy of public investments in the professional development of early childhood educators that are funded through the T.E.A.C.H. Early Childhood Project. This study of the T.E.A.C.H. Early Childhood Project Pennsylvania provides a longitudinal analysis of the data for the first three cohorts of applicants and scholars that participated in Pennsylvania's T.E.A.C.H. program. Over a 5-year period, we followed the scholars that participated in this program to examine the direct outcomes, as well as the indirect impact, of participating in the T.E.A.C.H. scholarship program. We found a number of positive outcomes for the scholars with respect to: educational achievement, increased compensation, reduced turnover, and improved knowledge, skill, and practice. The downside of T.E.A.C.H., as implemented in Pennsylvania, is keeping caregivers in the program. Only 15% of the scholars were still in the program at the end of the 5th year. The dropout/withdrawal rate after the first contract was 43.5% representing a sizable investment in scholars that never completed the initial contract. Based on these findings, the implications policy and practice are discussed.

How accessible is child care today?

The Government's 10-year child care strategy and the Childcare Act 2006 have established the framework for improving the provision of good quality child care for parents who need it in the UK. The number of day places for child care has increased, especially for full-time care and out-of-school clubs. There is now one place for every three children aged under eight years, but much needs to be done before care is available to all parents who need it. The cost of child care has risen above inflation and care for one child currently costs about one-third of the weekly earnings of a mother on an average wage. This puts child care beyond the reach of some low-income parents. There is a shortage of places for children with disabilities and for children of parents working outside normal office hours. Although efforts are being made to establish a better qualified and professional child care workforce, low pay and status make it difficult to recruit and retain suitable, high quality staff. More investment is needed in day care to bring the UK up to the level of Scandinavian countries.

Out-of-home day care for families living in a disadvantaged area of London: economic evaluation alongside a RCT

BACKGROUND

Children born into poverty have lifelong disadvantages compared with those more fortunate; social interventions seek to break this cycle of poverty and deprivation. Early Years Centres are one such intervention. These were established in deprived areas in the UK to provide high quality out-of-home day care. This paper reports the results of an economic evaluation conducted alongside a randomized controlled trial of one of these centres in the Borough of Hackney, London.

METHODS

Participants were randomized to receive either high quality day care as provided by the centre or to other child care that they secured for themselves where they chose to do so. Information on resource use (early years education and care, as well as health and social care) was collected over an 18-month period; this was valued using appropriate unit costs. The cost of education, social and health care together with the value of productivity gains and out-of-pocket costs were then compared with the effectiveness of the intervention, increased labour force participant in mothers.

RESULTS

From the societal perspective, the value of employment outweighs the costs of health and social services used, and in both groups there are cost savings. These are greater in the intervention group, therefore Early Years day care is an efficient use of resources. However, there is a net cost to the public sector of providing the intervention. The cost of achieving an additional mother in the labour force at 18 months is pound38 550 (85% CI of -pound1273, pound416 172).

CONCLUSION

From the societal perspective, over an 18-month period, all child care is cost saving, but high quality day care provided by the Early Years Centre is a cost-effective alternative to day care provided by other local services in Hackney. The public sector, however, incurs added expense from this intervention.

Children enrolled in public pre-K: the relation of family life, neighborhood quality, and socioeconomic resources to early competence

This article presents data on the family and social environments of 501 children enrolled in public sponsored pre-K in 5 states and tests the relation of these resources to child competence. Structured interviews and questionnaires provide information from parents about the family's social and economic status. Direct assessments and teacher reports provide data on children's literacy, numeracy, and behavioral problems. A majority of the children served in public pre-K lived in poverty and showed decrements in language but not in other domains. A socioeconomic resource factor consisting of parental education, household income, and material need predicted all domains of children's functioning. Children from households high in socioeconomic resources entered pre-K with more well developed language and math skill but fewer behavioral problems than their disadvantaged peers. Neighborhood quality status was related to language competence and mother's marital status to math competence. Neighborhood quality and income level may have their impact on child competence through their relation to dyadic quality and the health and the psychological well-being of the parents.

Household-based costs and benefits of vaccinating healthy children in daycare against influenza virus: results from a pilot study

BACKGROUND

Vaccinating children against influenza virus may reduce infections in immunised children and household contacts, thereby reducing the household-based cost associated with respiratory illnesses.

OBJECTIVE

To evaluate the impact of influenza virus vaccination of daycare children on costs of respiratory illnesses of the children and their household contacts from the household and societal perspective.

STUDY DESIGN

Cost analysis of data from a randomised controlled trial covering the period November to April of 1996-7 and 1998-9. Children (127 in 1996-7 and 133 in 1998-9) from daycare centres in Californian (USA) naval bases received influenza virus vaccine (inactivated) or hepatitis A virus vaccination.

OUTCOME MEASURES

Direct and indirect costs (1997 and 1999 US dollars) of respiratory illnesses in households of vaccinated and not vaccinated daycare children, excluding the cost of vaccination.

RESULTS

There were no statistically significant differences in household costs of respiratory illness between households with or without influenza virus-vaccinated children (USD 635 vs USD 492: p = 0.98 [1996-7]; USD 412.70 vs USD 499.50: p = 0.42 [1998-9]). In 1996-7, adult and 5- to 17-year-old contacts of vaccinated children had lower household costs than contacts of unvaccinated children (USD 58.50 vs USD 83.20, p = 0.01 and USD 32.80 vs USD 59.50, p = 0.04, respectively), while vaccinated children 0-4 years old had higher household costs than unvaccinated children in the same age group (USD 383 vs USD 236, p = 0.05). In 1998-9, there were no differences within individual age groups. Results from societal perspective were similar.

CONCLUSIONS

Overall, from both the household and societal perspectives, there were no economic benefits to households from vaccinating daycare children against influenza virus. However, we found some over-time inconsistency in results; this should be considered if changing recommendations about routine influenza virus vaccination of healthy children. Our study size may limit the generalisability of the results.

The welfare state as a determinant of women’s health: support for women’s quality of life in Canada and four comparison nations

The case is made that characteristics associated with the advanced welfare state in industrialised nations are primary contributors to women's quality of life. This is so since women's health and well-being are particularly sensitive to decisions made in relation to the spending priorities of governments, the extent to which services are provided, and the degree to which women are supported in moves towards equity. Data from the Organization for Economic Cooperation and Development, United Nations Human Development Program, and other sources are used to examine these influences upon quality of life of women in Canada as compared to that of women in Denmark, Sweden, the UK and the US. A consistent pattern was seen by which national features impacting on women's quality of life are more likely to be seen in nations with a social welfare orientation as compared to nations with market approaches to policy development.

Health care utilization and expenditures associated with child care attendance: a nationally representative sample

OBJECTIVE

Participation in center-based child care among preschool-aged children is associated with an increased incidence of communicable illness. Although estimates of health care utilization and costs associated with child care attendance exist in other countries with different health care systems, nationally representative data for the United States are lacking. The objective of this study was to determine the patterns of health care utilization and costs associated with attendance at different types of child care, among a nationally representative sample of preschool-aged children.

METHODS

A nationally representative sample of children aged 0 to 5 years enrolled in the Medical Expenditure Panel Survey, 1997 Cohort were studied. Data were analyzed by cross-sectional analysis within a single calendar year. The Rand Health Insurance experiment 2-part multivariate regression model was used to accommodate skewed expenditure data.

RESULTS

A total of 871 children were included in the study. A total of 484 (56%) attended no child care provided by anyone other than their primary caregiver; 134 (15%) attended center-based child care; 76 (9%) attended friend or neighbor care; and 170 (20%) attended in-home or relative care. In a weighted multivariate model, children in center-based child care were more likely than those not in child care to have attended at least 1 office-based visit (adjusted odds ratio [aOR]: 2.8; 95% confidence interval [CI]: 1.0-7.9) and emergency department visit (aOR: 2.0; 95% CI: 1.1-3.6) and to have received a medication prescription (aOR: 2.8; 95% CI: 1.2-6.1). The adjusted 2-part model predicted total health care expenditures for those not attending child care to be 642 dollars (95% CI: 508-813), versus 985 dollars (95% CI: 714-1336) for a similar population in center-based child care. Expenditure data for office-based visits and medication prescriptions mirrored these trends.

CONCLUSION

In the immediate term, children in center-based child care tend to use more health care services. This increased utilization translates into modest per-child differences in health care expenditures. We hypothesize that this pattern of utilization and expenditure is attributable primarily to a higher incidence of minor, self-limited, communicable illness among children in center-based child care.

Federal child care funding for low-income families: how much is needed?

Setting a dollar amount for government spending on child care is a major issue in reauthorizing the 1996 welfare reform law. Two key components in pending Congressional proposals involve the Temporary Assistance for Needy Families block grant and the Child Care and Development Fund, which together provide the bulk of government child care funding for low income working families, whether or not these families are directly involved in the welfare system. The choices for Congress involved in setting an appropriate child care funding level are complex and fraught with questions about quality and cost tradeoffs. This issue brief provides background on current child care use, arrangements, and cost, as well as research findings on the measurement of quality in child care programs.

Child care subsidies and the employment of welfare recipients

Changing patterns of maternal employment, coupled with stronger work requirements for welfare recipients, are increasing the demand for child care. For many families, the cost of child care creates a financial burden; for mothers with low incomes and those who are former welfare recipients, these costs may be an insurmountable barrier to employment or economic self-sufficiency. Despite increased public spending in this area, the receipt of any child care subsidy appears to be a relatively rare and uncertain event. In this study, we use data from a sample of low-income single mothers (current and recent welfare recipients in California) to estimate the probability of their receiving child care subsidies and the effect of this probability on labor market activity.

A dynamic analysis of the effect of child care costs on the work decisions of low-income mothers with infants

Child care costs reduce the net benefit of working and consequently influence mothers' decisions to work. They affect the employment of low-income mothers in particular because they represent a larger portion of these mothers' earnings. I used a hazard framework to examine a mother's decisions about work and hours of work after childbirth. I focused on low-income mothers with infants because they are the ones who may be most affected by child care costs. The results showed that child care costs are a barrier to work that is larger for low-income mothers than for non-low-income mothers. Further, child care costs have large negative effects on hours of work.

Ensuring quality and sustainability in after-school programs

The Charles Stewart Mott Foundation and the U.S. Department of Education are engaged in a unique public-private partnership that strives to integrate the assets and flexibility of philanthropy with the breadth of a major federal program to support meaningful after-school programs and school-community partnerships for children, youth, families, and communities.

Economic impact of an infection control education program in a specialized preschool setting

OBJECTIVE

To assess the economic impact, from a societal perspective, of a multidimensional infection control education program (ICEP) in a preschool for children with Down syndrome.

METHODS

Krilov et al implemented a comprehensive ICEP in a specialized preschool setting and reported a significant decrease in medical resource utilization and days absent from school. Clinical and economic data from Krilov et al and other sources were incorporated into a health-state transition (Markov) decision analysis model that estimated annual expected costs for the baseline and intervention years. Procedure and diagnosis codes were assigned to all physician office visits, emergency department visits, hospitalizations, and laboratory and diagnostic tests. Cost estimates then were derived using 1999 national reimbursement schedules and other sources. Productivity losses for parents were estimated using national wage rates. The costs of the ICEP were compared with the reduction in the costs of illness (direct medical costs plus costs associated with lost parental working time). The outcomes measured were mean annual costs of illness per child, total annual ICEP costs, and net annual costs or savings.

RESULTS

With a comprehensive ICEP, the mean costs of illness in the baseline year was $1235 per child, of which 68% and 14% were for productivity losses and physician visits, respectively. In the intervention year, the mean costs of illness per child was $615, of which 71% and 20% were for productivity losses and physician visits, respectively. The cost of the preexisting infection control (IC) practices in place at the onset of the study (baseline year) was $716. The comprehensive ICEP cost (intervention year) was $75 627, 92% of which was spent to hire a cleaning service to decontaminate toys 3 times per week. When a secondary analysis was performed to reflect a less intensive ICEP in a nonspecialized preschool setting, the mean costs of illness in the baseline and intervention years were $962 and $614 per child, respectively, representing a total annual cost-of-illness savings of $13 224 for the 38 children who participated in the study by Krilov et al. The annual incremental cost of the less intensive ICEP was $2371; therefore, the estimated net annual savings of the less intensive ICEP in a nonspecialized preschool was $10 853.

CONCLUSIONS

This study suggests that the reduction in the costs of illness could more than offset the cost of implementing a multidimensional ICEP in a preschool setting.

Childcare support

In this third article of this new series, Lesley Fudge outlines the government strategy on improving childcare support for healthcare workers.

Child care in Slovenia: an example of a successful transition

Slovenia is a country which has managed to retain most of its advantages and achievements in preschool child care attained in the socialist period, while, during the transition years, rather successfully reforming services according to principles of the market economy. The female activity rate has been high since the mid 1940s, and female employment has been the main factor influencing the demand for preschool child care services. Slovenian mothers work full-time and after 1 year of paid maternity and parental leave they mostly stay in the labour market. Child care facilities, 70% of them constructed in the period 1971-1985, are sufficient for almost 60% of the preschool population, and just a very small percentage of demand remains unmet. Child care services are traditionally highly subsidised. On average, parents finance up to a quarter of the current costs, so that the average in-kind transfer for a child in child care amounts to about 30% of the average net salary. Social assistance recipients are exempt from paying fees altogether, while the rest of the parents pay from 15% to 80% of the current costs. The highest fee is paid by families with a per capita income > 110% of the average salary in Slovenia. Research into the burden of parental fees for child care in Ljubljana in 1994 has shown that three-quarters of families spent between 5 and 15% of their total net income on child care (for one or more children). For three-quarters of families, the total of fees paid did not exceed 30% of their net income per family member. The lower middle income group was relatively most burdened by child care fees.

Socio-economic differences in daycare arrangements and use of medical care and antibiotics in Swedish preschool children

In this study we describe socio-economic patterns of daycare enrolment, medical care and antibiotics in children, 0-5 y, whose parents participated in the Swedish Survey of Living Conditions 1996-97. Children in families with low socio-economic status and unemployed parents were less often enrolled in out-of-home care. Multivariate analyses (adjusted for various sociodemographic indicators, type of daycare and chronic morbidity) demonstrated that children 1-5 y in families with low social status (low parental education and/or low SES) were less likely to have paid a visit to a physician because of an acute infection during the previous 3 mo [odds ratio (OR) 0.6 (0.4-0.8)] or to have consumed antibiotics during the previous 12 mo [OR 0.8 (0.6-1.0)] compared to children with a higher social status. Children in out-of-home care more often had paid a visit to a physician because of an acute infection during the previous 3 mo [OR 1.5 (1.2-1.9)] and more often had consumed antibiotics during the previous 12 mo [OR 1.7 (1.3-2.1)] than children in home care. The effect of out-of-home care on use of medical care and antibiotics decreased with increasing age of the child, and deviated from the null hypothesis in children 1-3 y only.

CONCLUSION

Preschool children in families with a low social status consume less medical care and are less likely to attend out-of-home care compared to children with a higher social status in Swedish society. This inequity needs to be addressed in social and health policy.

For profit versus non-profit: does economic sector make a difference in child-care?

The child-care industry in a large, southeastern community serves as this study's vehicle for comparing non-profit with for profit dependent care in areas not easily observable to clients. The cross-sectional analysis compares child-care centers on marketed and actual staff-to-child ratio; staff salary; consistency in the child's group environment; staff stability; and extent of parental involvement. Findings are based on self-reports of directors and support hypotheses derived from the theory that for profit day care centers will use their discretionary authority to vary the care environment to achieve profit goals despite the potential effect on the quality of the child's environment. Further, despite potential cost economies and enhanced quality of care achievable as a non-profit entity, few for profit center directors consider becoming non-profit centers.

Assessing the requirements of hospital-sponsored child daycare

Staff shortages have made many hospitals consider providing child daycare for employees. This article summarizes employee expectations and the market findings of an analysis conducted at Shands Hospital at the University of Florida. It evaluates the financial feasibility of a child daycare center and discusses factors that make child daycare a questionable business venture. It also looks at strategies for enhancing available child daycare without providing services directly.

[Children in the Estado Novo: a reading of long duration]

O artigo trata do discurso que justificou a constituição do programa de proteção materno-infantil lançado durante o Estado Novo, em 1940, a partir da criação do Departamento Nacional da Criança. Sustenta-se aqui a idéia de que ele correspondeu a uma leitura conservadora da metáfora dualista, formalizada no século XVIII, que resultou em demonização do adulto e endeusamento da criança. Para tanto, o discurso é remontado em seus elementos fundamentais e comparado com duas interpretações diferentes sobre o mesmo tema, com as quais se defrontou: a proposta de política social do movimento feminista (dos anos 30) e uma análise crítica do sociólogo Guerreiro Ramos. Ao fim, procura-se demonstrar que elementos inscritos na mentalidade coletiva podem ser lidos de maneiras diversas.

Child and Adult Care Food Program: improved targeting of day care home reimbursements--Food and Consumer Service, USDA. Final rule

This final rule amends the Child and Adult Care Food Program regulations governing reimbursement for meals served in family day care homes by incorporating changes resulting from the Department's review of comments received on a January 7, 1997, interim rule. These changes and clarifications involve: The appropriate use of school and census data for making tier I day care home determinations; documentation requirements for tier I classifications; tier II day care home options for reimbursement, including use of child care vouchers; calculating claiming percentages/blended rates using attendance and enrollment lists; and procedures for verifying household applications of children enrolled in day care homes. This final rule also amends the National School Lunch Program regulations to facilitate tier I day care home determinations by requiring school food authorities to provide elementary school attendance area information to sponsoring organizations. These revisions implement in final form the provisions of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 to target higher CACFP reimbursements to low-income children and providers.

Arranging child care

More than half of the children in families supported by welfare are under age six, and another third are in grade school. The mothers of these children cannot leave welfare for employment unless they can find and pay for child care. Yet, as this article points out, the child care needs of these families are not easily met: Many require care for infants and toddlers, care at odd hours, and care in poor neighborhoods-all of which are scarce. Evidence reviewed by the authors indicates that problems with child care affordability, availability, and quality impede mothers from participating in the labor force and in job training programs. Recent public finding for child care subsidies has helped families leaving welfare to afford the child care they need, although the demand for financial assistance outstrips available funding. This article urges that policymakers work to facilitate access to subsidies, increase the supply of care that can meet the needs of poor working families, and guard against exposure to poor-quality care that can jeopardize both children's well-being and parents' employment.

A brief history of federal financing for child care in the United States

Over the past 60 years, the federal government has provided funding for child care and early education programs in fits and starts. Funding has fluctuated in amount and purpose, with the result that today's child care financing system is a confused collection of funding streams with no uniform goals, standards, or administrative structure. This article traces the history of federal funding for child care and early education programs in the United States and examines how the values of American society have shaped the federal funding of child care and early education services.

Funding child care and public education

Ensuring the availability of high-quality, affordable child care to all families who need it is a goal of national importance. The authors suggest that a comprehensive financing and service delivery system for child care is needed to achieve this goal, and the system should ideally be grounded in an existing institution, already present in every community--the public school. The linkage of child care with the public education system would eliminate the false distinction between child care and education, and would create a universally accessible system of child care services for children. The School of the 21st Century is an example of such a system. Initially conceptualized by Zigler, it has now been implemented in 400 schools across 13 states, with the leadership and direction of Finn-Stevenson. This article describes how school districts that have implemented the program employ a mixture of parent fees and local, state, federal, and private dollars to fund it, and then proposes an ideal financing model for the program. In the ideal model, the same mix of funding sources would be retained, but a per-pupil expenditure of about $9,000 per year is advocated to deliver child care and other social services to three- and four-year-olds. Funds for initial start-up could be derived from reallocation of existing dollars, especially state prekindergarten programs, but eventually new funds would be needed to support ongoing operations.

Child-care practices: effects of social change on the epidemiology of infectious diseases and antibiotic resistance

The increasing number of mothers of young children in the work force and the resultant escalated use of child-care facilities has had a marked effect on the epidemiology of infectious diseases in young children. Children attending child care are at high risk for respiratory and gastrointestinal tract illnesses. The high prevalence of infectious diseases in the child-care setting is accompanied by high usage of antibiotics, which in turn has resulted in spread of antibiotic-resistant organisms. The infectious disease standards of the American Public Health Association/American Academy of Pediatrics guidelines were developed to prevent and limit transmission of infectious diseases in the child-care setting. Adherence to these standards is essential but will not completely eliminate the increased risk of infectious diseases in child-care settings. New challenges need to be addressed to assure that optimal health promotion and disease prevention is practiced in child-care settings. We approach the 21st century with a vast amount of medical knowledge, molecular technology, highly effective vaccines, and powerful antimicrobial agents. However, at the same time we face many unsolved serious problems, such as preventing or controlling the emergence and spread of antibiotic-resistant organisms that adversely affect our ability to treat infectious diseases. Further research is needed concerning the relations between child care, the use of antibiotics, and transmission of antibiotic-resistant organisms in order to design and implement the most effective strategies for preventing or controlling antibiotic resistance. The potential risk for transmission of HIV in the child-care setting also needs to be recognized, and procedures to prevent transmission of blood-borne pathogens need to be followed. Monitoring compliance with national standards for child-care facilities, dissemination of information concerning infectious diseases and use of antibiotics, and development and use of new vaccines are strategies which should be used to help protect the health of children in child-care environments.

Child care cost and quality

This article summarizes what is known about the cost and quality of full-time child care in centers and family child care homes, and about parents' attention to quality in making child care choices. It relies primarily upon two recent studies which are among the first to collect detailed information about child care operating costs: the Cost, Quality, and Child Outcomes in Child Care Centers study and the Economics of Family Child Care study. Results indicate that mediocre quality is the rule and that parents often do not choose quality settings for their children. At the present time, child care quality is only modestly related to the cost of providing services. In part, the modesty of this relationship reflects the low wages of child care staff, the availability of in-kind donations in the nonprofit sector, and the altruistic motivations of many providers that depress direct costs and the fees charged for child care. The article concludes with recommendations of future: (1) launch consumer education efforts; (2) implement higher standards for child care at the state level; (3) avoid public policies that encourage people to become child care providers if they have no interest in such a career; (4) increase public and private investments in child care; and (5) develop the means to compensate child care workers as is appropriate for their levels of training, experience, and responsibility.

Use of educational resource materials with South African children in day care

The psychometric scores of black South African children (N = 248) in 16 day-care centers were assessed before (n = 119) and after (n = 129) the introduction of an enrichment package, which consisted of a range of educational toys and cost US $12 per child. Analysis indicated that the enrichment was associated with significant improvements on a number of psychometric measures. Results are critically examined in terms of methodological issues, the effects of a low-cost enrichment scheme, and aspects of the package which merited subsequent improvement.

Interagency coordination: the key to mainstreaming children with special needs into day care

While the need for mainstreamed day-care services continues to increase, many barriers remain that prevent or delay providers from enrolling children with special needs. The suggestions in this article to coordinate local resources will help programs begin to provide initial necessary services to children with special needs. The use of volunteers will help supplement the staffing needs of a day-care center and allow for more individualized care of the children. Unfortunately, the absence of public funds for child day care continues to be a major barrier to creating appropriate programs for children with special needs. State and federal policies need to be expanded to support day care in general and children with special needs specifically. Part H of PL 99-457 (now Part H of IDEA PL102-119) is a national impetus to promote interagency collaboration at state and local levels. This is a beginning, but more state and federal funding is needed. In addition, regulations need to be developed that will make it easier rather than more difficult for local agencies to participate. Day-care providers and professionals in every community must work together to provide appropriate services to children with special needs. The most effective services use interdisciplinary teams to work together to plan and implement the care. Let us pick up the challenge of this mandate and develop programs that will help future generations recognize and accept the differences between individuals as well as see the similarities.