摘要：Objectives. We compared estimates for children with and without special health care needs (SHCN) at 2 time periods for national health objectives related to the Healthy People 2010 leading health indicators (LHIs). Methods. Data were from the 2003 and 2007 National Surveys of Children’s Health. Seven survey items were relevant to the LHIs and available in both survey years: physical activity, obesity, household tobacco use, current insurance, personal health care provider, past-month depressive symptoms, and past-year emergency department visits. Results. In 2003 and 2007, children with SHCN fared worse than those without SHCN with respect to physical activity, obesity, household tobacco exposure, depressive symptomology, and emergency department visits, but fared better on current insurance and having a personal health care provider. Physical activity and access to a personal health care provider increased for all children, whereas the absolute disparity in personal provider access decreased 4.9%. Conclusions. Significant disparities exist for key population health indicators between children with and without SHCN. Analyses illustrated how population-based initiatives could be used to frame health challenges among vulnerable populations. Now in its fourth generation, Healthy People (HP) is a strategic framework for achieving national goals for the health and well-being of all Americans. Each decade, progress toward these goals is monitored using evidence-based objectives that establish targets for the next 10 years. 1–3 The close of the previous decade offered the opportunity to assess progress toward the 467 objective targets 4–6 of HP 2010 and the initiative’s 2 overarching goals: (1) to increase quality and years of healthy life, and (2) to eliminate health disparities. With the release of HP 2020, this second goal reflects a 3-decade commitment to addressing health disparities, including those specific to individuals living with disabilities such as children with special health care needs (CSHCN). The Federal Maternal and Child Health Bureau (MCHB) defines CSHCN as those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition, and who also require health and related services of a type or amount beyond that required for children generally. 7 Three survey systems, the National Survey of Children’s Health (NSCH), the National Survey of Children with Special Health Care Needs (NS-CSHCN), and the Medical Expenditure Panel Survey, use this definition. This definition, operationalized in a 5-item screener, reflects children who experience both a wide range of conditions and related consequences. As such, the definition differs from measures used to track some HP objectives, which focus primarily on functional- and activity-related limitations. 8 This distinction is important because although all children living with a functional limitation would be considered as having a SHCN, not all CSHCN are functionally limited. 9 The broader focus on both needs and consequences of health conditions allows for a more comprehensive analysis of this group within the context of the general pediatric population. Historically, measuring progress across HP 2010 objectives for CSHCN has been challenging for 3 reasons. First, although disability status was among the characteristics for which population-based objectives could be tracked for the purposes of monitoring progress toward the elimination of health disparities, estimates by disability status were only produced for selected indicators. In some cases, data on disability status were available but not analyzed or were determined by the sponsoring agency as not meeting the criteria for statistical reliability, quality, or confidentiality; HP estimates are published in accordance with the data protocols and analytic practices of the data provider or sponsoring agency of each data system. In others, data on disability status were not collected. Second, for those objectives where disability status was reported, separate estimates for subgroups within this population (e.g., children) were not systematically produced. As such, it was not possible to monitor progress for children with disabilities across all HP 2010 objectives. Third, estimates for individuals with disabilities might vary considerably by the definition of disability utilized. Because HP objectives are tracked using multiple data systems, comparisons across indicators for individuals with disabilities were not always available or comparable for all indicators. Efforts to track HP objectives for CSHCN and children with disabilities 10 are illustrated in the Appendix (data available as a supplement to the online version of this article at http://www.ajph.org ). HP 2010 tracked 2 objectives for CSHCN as defined by MCHB. These objectives included medical home access (objectives 16–22) and receipt of care in family-centered, comprehensive and coordinated systems (objectives 16–23). 11 Six additional objectives were either tracked for children with disabilities using other definitions of disability or estimates for children with disabilities were produced as a subpopulation of interest. Because they were organized across different HP focus areas and relied on different data systems, these indicators provided a limited picture of the health and well-being of children with chronic conditions and related SHCN. Previous research on health disparities between children with and without SHCN or disabilities has focused predominantly on differences in health care access, utilization, and expenditures, 12–16 and to a lesser extent on selected heath status indicators. 13,17 However, comparisons relative to children without SHCN are ultimately important to monitoring programmatic efforts to improve outcomes and reduce the excess burden of ill health experienced by CSHCN. National efforts, including HP, are commonly used to support social policy development, implementation, and monitoring of efforts to address such public health challenges and disparities. Scholars examining policy processes and implementation through governmental agencies and related organizational structures describe such agenda-setting activities as important tools in the bureaucratic process. 18–20 In the maternal and child health arena, Title V of the Social Security Act explicitly links the purpose of the national maternal and child health program to national health objectives, including HP. The dearth of comparable data for tracking CSHCN health status within the HP framework places stewards of public health programs for this population at a disadvantage. Furthermore, research indicating that CSHCN includes both a sizable 21 and growing 22 segment of the US pediatric population underscores the importance of efforts to address the health of this population within the larger framework of population-based public health initiatives like HP. The goal of this study was to provide a systematic assessment of key national health objectives, traditionally tracked for the population as a whole, but rarely reported or summarized for CSHCN using data from the NSCH. The NSCH is the only nationally representative survey that provides comparable data on the health and development of children with and without SHCN. We compared estimates for children with and without SHCN at 2 time periods for HP 2010 objectives selected according to the 2010 leading health indicators (LHIs). Disparities and temporal patterns were highlighted, and implications for practice and program planning were discussed.
