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Tackling the Social Determinants of Health: A Critical Component of Safe and Effective Healthcare. Pediatr Qual Saf 2018; 3:e054. [PMID: 30280123 PMCID: PMC6132767 DOI: 10.1097/pq9.0000000000000054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/05/2018] [Indexed: 11/26/2022] Open
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Geospatial mapping can be used to identify geographic areas and social factors associated with intentional injury as targets for prevention efforts distinct to a given community. J Trauma Acute Care Surg 2018; 84:70-74. [PMID: 29040200 DOI: 10.1097/ta.0000000000001720] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Geographic information systems (GIS) have proven effective in studying intentional injury in various communities; however, GIS is not implemented widely for use by Level I trauma centers in understanding patient populations. Our study of intentional injury combines the capabilities of GIS with a Level I trauma center registry to determine the spatial distribution of victims and correlated socioeconomic factors. METHODS One thousand ninety-nine of 3,109 total incidents of intentional trauma in the trauma registry from 2005 to 2015 had sufficient street address information to be mapped in GIS. Comparison of these data, coupled with demographic data at the block group level, determined if any clustering or spatial patterns existed. Geographic information systems delivered these comparisons using several spatial statistics including kernel density, ordinary least squares test, and Moran's index. RESULTS Kernel density analysis identified four major areas with significant clustering of incidents. The Moran's I value was 0.0318. Clustering exhibited a positive z-score and significant p value (p < 0.01). Examination of socioeconomic factors by spatial correlation with the distribution of intentional injury incidents identified three significant factors: unemployment, single-parent households, and lack of a high school degree. Tested factors did not exhibit substantial redundancy (variance inflation factor < 7.5). Nonsignificant tested factors included race, proximity to liquor stores and bars, median household income, per capita income, rate with public assistance, and population density. CONCLUSION Spatial representation of trauma registry data using GIS effectively identifies high-risk areas for intentional injury. Analysis of local socioeconomic data identifies factors unique to those high-risk areas in the observed community. Implications of this study may include the routine use of GIS by Level I trauma centers in assessing intentional injury in a given community, the use of that data to guide the development of trauma prevention, and the assessment of other mechanisms of trauma using GIS. LEVEL OF EVIDENCE Epidemiological, level IV.
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Ginn CS, Mughal MK, Syed H, Storteboom AR, Benzies KM. Sustaining Engagement in Longitudinal Research With Vulnerable Families: A Mixed-Methods Study of Attrition. JOURNAL OF FAMILY NURSING 2017; 23:488-515. [PMID: 29117759 DOI: 10.1177/1074840717738224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The aim of this mixed-methods study was to investigate attrition at the age 10-year follow-up in a study of vulnerable children and their families living with low income following a two-generation preschool program in Calgary, Alberta, Canada. Quantitative factors associated with attrition included: (a) food bank use; (b) unstable housing; (c) child welfare involvement; (d) unpartnered status; and (e) caregiver noncompletion of high school. Qualitative themes related to attrition included: (a) income and employment; (b) health; (c) unstable housing; (d) change of guardianship; (e) domestic violence; (f) work and time management challenges; and (g) negative caregiver-child relationships. Triangulation of quantitative and qualitative results occurred using Maslow's Hierarchy of Needs; families with unmet physiological, safety, belongingness and love needs, and esteem needs were more likely to attrite. Attrition in longitudinal studies with vulnerable families is complex, affected by frequently changing life circumstances, and struggles to access necessities of life. Strategies for retaining vulnerable families in longitudinal research are offered.
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Affiliation(s)
| | | | - Hafsa Syed
- 2 Calgary Urban Project Society (CUPS) Health Education Housing, Alberta, Canada
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Palakshappa D, Doupnik S, Vasan A, Khan S, Seifu L, Feudtner C, Fiks AG. Suburban Families' Experience With Food Insecurity Screening in Primary Care Practices. Pediatrics 2017. [PMID: 28634248 DOI: 10.1542/peds.2017-0320] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Food insecurity (FI) remains a major public health problem. With the rise in suburban poverty, a greater understanding of parents' experiences of FI in suburban settings is needed to effectively screen and address FI in suburban practices. METHODS We conducted 23 semistructured interviews with parents of children <4 years of age who presented for well-child care in 6 suburban pediatric practices and screened positive for FI. In the interviews, we elicited parents' perceptions of screening for FI, how FI impacted the family, and recommendations for how practices could more effectively address FI. All interviews were audio recorded and transcribed. We used a modified grounded theory approach to code the interviews inductively and identified emerging themes through an iterative process. Interviews continued until thematic saturation was achieved. RESULTS Of the 23 parents interviewed, all were women, with 39% white and 39% African American. Three primary themes emerged: Parents expressed initial surprise at screening followed by comfort discussing their unmet food needs; parents experience shame, frustration, and helplessness regarding FI, but discussing FI with their clinician helped alleviate these feelings; parents suggested practices could help them more directly access food resources, which, depending on income, may not be available to them through government programs. CONCLUSIONS Although most parents were comfortable discussing FI, they felt it was important for clinicians to acknowledge their frustrations with FI and facilitate access to a range of food resources.
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Affiliation(s)
- Deepak Palakshappa
- Department of Pediatrics, .,Center for Pediatric Clinical Effectiveness and PolicyLab, and.,Healthy Weight Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephanie Doupnik
- Department of Pediatrics.,Center for Pediatric Clinical Effectiveness and PolicyLab, and
| | | | - Saba Khan
- Healthy Weight Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Leah Seifu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Department of Pediatrics.,Center for Pediatric Clinical Effectiveness and PolicyLab, and.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander G Fiks
- Department of Pediatrics.,Center for Pediatric Clinical Effectiveness and PolicyLab, and.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Veríssimo MDLÓR. The irreducible needs of children for development: a frame of reference to health care. Rev Esc Enferm USP 2017; 51:e03283. [PMID: 29562042 DOI: 10.1590/s1980-220x2017017403283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/17/2017] [Indexed: 11/22/2022] Open
Abstract
A comprehensive health care to children implies in caring for their development, by perceiving the needs based on a suitable reference to children's specificities. This theoretical study aimed to analyze the "irreducible needs of children" frame of reference, based on a child development theory. We performed a comparative analysis between the contents of children's irreducible needs and the components of the Bioecological Theory of Human Development. An extensive correspondence was verified among the components of the Bioecological Theory and the following essential needs: ongoing nurturing relationships; experiences tailored to individual differences; developmentally appropriate experiences; limit setting, structure and expectations; stable, supportive communities and cultural continuity. The need for physical protection, safety, and regulation is not explicit in the elements of the theory, although it is also verified in their definitions. We concluded that the irreducible needs' reference can support nurses in health care and in child development promotion.
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Raphael JL, Colvin JD. More than wheezing: incorporating social determinants into public policy to improve asthma outcomes in children. Pediatr Res 2017; 81:2-3. [PMID: 27849195 DOI: 10.1038/pr.2016.223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jean L Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, Texas
| | - Jeffrey D Colvin
- Department of Pediatrics, The Children's Mercy Hospital and Clinics, Kansas City, Missouri
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Beck AF, Huang B, Auger KA, Ryan PH, Chen C, Kahn RS. Explaining Racial Disparities in Child Asthma Readmission Using a Causal Inference Approach. JAMA Pediatr 2016; 170:695-703. [PMID: 27182793 PMCID: PMC5503118 DOI: 10.1001/jamapediatrics.2016.0269] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Childhood asthma is characterized by disparities in the experience of morbidity, including the risk for readmission to the hospital after an initial hospitalization. African American children have been shown to have more than 2 times the hazard of readmission when compared with their white counterparts. OBJECTIVE To explain why African American children are at greater risk for asthma-related readmissions than white children. DESIGN, SETTING, AND PARTICIPANTS This study was completed as part of the Greater Cincinnati Asthma Risks Study, a population-based, prospective, observational cohort. From August 2010 to October 2011, it enrolled 695 children, aged 1 to 16 years, admitted for asthma or wheezing who identified as African American (n = 441) or white (n = 254) in an inpatient setting of an urban, tertiary care children's hospital. MAIN OUTCOMES AND MEASURES The main outcome was time to asthma-related readmission and race was the predictor. Biologic, environmental, disease management, access, and socioeconomic hardship variables were measured; their roles in understanding racial readmission disparities were conceptualized using a directed acyclic graphic. Inverse probability of treatment weighting balanced African American and white children with respect to key measured variables. Racial differences in readmission hazard were assessed using weighted Cox proportional hazards regression and Kaplan-Meier curves. RESULTS The sample was 65% male (n = 450), and the median age was 5.4 years. African American children were 2.26 times more likely to be readmitted than white children (95% CI, 1.56-3.26). African American children significantly differed with respect to nearly every measured biologic, environmental, disease management, access, and socioeconomic hardship variable. Socioeconomic hardship variables explained 53% of the observed disparity (hazard ratio, 1.47; 95% CI, 1.05-2.05). The addition of biologic, environmental, disease management, and access variables resulted in 80% of the readmission disparity being explained. The difference between African American and white children with respect to readmission hazard no longer reached the level of significance (hazard ratio, 1.18; 95% CI, 0.87-1.60; Cox P = .30 and log-rank P = .39). CONCLUSIONS AND RELEVANCE A total of 80% of the observed readmission disparity between African American and white children could be explained after statistically balancing available biologic, environmental, disease management, access to care, and socioeconomic and hardship variables across racial groups. Such a comprehensive, well-framed approach to exposures that are associated with morbidity is critical as we attempt to better understand and lessen persistent child asthma disparities.
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Affiliation(s)
- Andrew F. Beck
- Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio2Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohi
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Katherine A. Auger
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Patrick H. Ryan
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Chen Chen
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Robert S. Kahn
- Division of General and Community Pediatrics, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
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Financial and Social Hardships in Families of Children with Medical Complexity. J Pediatr 2016; 172:187-193.e1. [PMID: 26897040 PMCID: PMC4846519 DOI: 10.1016/j.jpeds.2016.01.049] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/22/2015] [Accepted: 01/20/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To describe hardships experienced by families of children with medical complexity (CMC) and compare them with those experienced by families of children with asthma. STUDY DESIGN We assessed hardships in a cohort of 167 families of CMC. Surveys assessed sociodemographics and hardships (eg, financial: inability to pay bills; social: limited help from family/friends). CMC cohort hardships were compared with those of an established cohort of children hospitalized with asthma using multivariable logistic regression. RESULTS CMC had diagnoses in a median of 5 different complex chronic condition categories (most common neurologic/neuromuscular), and the majority (74%) were dependent on technology. Over 80% of families of CMC reported experiencing ≥1 hardship; 68% with financial and 46% with social hardship. Despite higher socioeconomic status than families with asthma, families of CMC often experienced more hardships. For example, families of CMC were significantly more likely to report failure to pay rent/mortgage (aOR 2.6, 95% CI 1.6, 4.3) and the expectation of little to no help from family/friends (aOR 2.9, 95% CI 1.9, 4.7). CONCLUSIONS Families of CMC frequently report financial and social hardships, often at rates higher than families with asthma who were generally of lower socioeconomic status. Identifying and acting upon hardships may be an important addition to the care of CMC.
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Plax K, Donnelly J, Federico SG, Brock L, Kaczorowski JM. An Essential Role for Pediatricians: Becoming Child Poverty Change Agents for a Lifetime. Acad Pediatr 2016; 16:S147-54. [PMID: 27044693 DOI: 10.1016/j.acap.2016.01.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/13/2016] [Accepted: 01/15/2016] [Indexed: 10/22/2022]
Abstract
Poverty has profound and enduring effects on the health and well-being of children, as well as their subsequent adult health and success. It is essential for pediatricians to work to reduce child poverty and to ameliorate its effects on children. Pediatricians have important and needed tools to do this work: authority/power as physicians, understanding of science and evidence-based approaches, and first-hand, real-life knowledge and love of children and families. These tools need to be applied in partnership with community-based organizations/leaders, educators, human service providers, business leaders, philanthropists, and policymakers. Examples of the effects of pediatricians on the issue of child poverty are seen in Ferguson, Missouri; Denver, Colorado; and Rochester, New York. In addition, national models exist such as the American Academy of Pediatrics Community Pediatrics Training Initiative, which engages numerous pediatric faculty to learn and work together to make changes for children and families who live in poverty and to teach these skills to pediatric trainees. Some key themes/lessons for a pediatrician working to make changes in a community are to bear witness to and recognize injustice for children and families; identify an area of passion; review the evidence and gain expertise on the issue; build relationships and partnerships with community leaders and organizations; and advocate for effective solutions.
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Affiliation(s)
- Katie Plax
- Department of Pediatrics, Washington University School of Medicine, St Louis, Mo; American Academy of Pediatrics, Community Pediatrics Training Initiative, Elk Grove Village, Ill.
| | - Jeanine Donnelly
- American Academy of Pediatrics, Community Pediatrics Training Initiative, Elk Grove Village, Ill
| | | | - Leonard Brock
- United Way of Greater Rochester, Rochester-Monroe Anti-Poverty Initiative, NY
| | - Jeffrey M Kaczorowski
- American Academy of Pediatrics, Community Pediatrics Training Initiative, Elk Grove Village, Ill; University of Rochester Medical Center, Golisano Children's Hospital, NY
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Beck AF, Tschudy MM, Coker TR, Mistry KB, Cox JE, Gitterman BA, Chamberlain LJ, Grace AM, Hole MK, Klass PE, Lobach KS, Ma CT, Navsaria D, Northrip KD, Sadof MD, Shah AN, Fierman AH. Determinants of Health and Pediatric Primary Care Practices. Pediatrics 2016; 137:e20153673. [PMID: 26933205 DOI: 10.1542/peds.2015-3673] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2015] [Indexed: 11/24/2022] Open
Abstract
More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.
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Affiliation(s)
- Andrew F Beck
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio;
| | - Megan M Tschudy
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Tumaini R Coker
- Department of Pediatrics, David Geffen School of Medicine and Mattel Children's Hospital, Los Angeles, California
| | - Kamila B Mistry
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland; Agency for Healthcare Research and Quality; Rockville, Maryland
| | - Joanne E Cox
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Benjamin A Gitterman
- Department of Pediatrics, Children's National Health System; Washington, District of Columbia
| | - Lisa J Chamberlain
- Department of Pediatrics, Lucile Packard Children's Hospital, Palo Alto, California
| | - Aimee M Grace
- Office of US Senator Brian Schatz (D-HI) and George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Michael K Hole
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Perri E Klass
- Department of Pediatrics, New York University School of Medicine, New York, New York
| | - Katherine S Lobach
- Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Christine T Ma
- Department of Pediatrics, UCSF Benioff Children's Hospital Oakland, Oakland, California
| | - Dipesh Navsaria
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kimberly D Northrip
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky; and
| | - Matthew D Sadof
- Department of Pediatrics, Baystate Children's Hospital, Springfield, Massachusetts
| | - Anita N Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Arthur H Fierman
- Department of Pediatrics, New York University School of Medicine, New York, New York
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Moving From Social Risk Assessment and Identification to Intervention and Treatment. Acad Pediatr 2016; 16:97-8. [PMID: 26791277 DOI: 10.1016/j.acap.2016.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 01/07/2016] [Indexed: 11/22/2022]
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