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Assaf RR, Assaf RD, Padlipsky PS, Young KDA. A family-centered approach to social needs awareness in the pediatric emergency department. PEC INNOVATION 2024; 4:100283. [PMID: 38689830 PMCID: PMC11059452 DOI: 10.1016/j.pecinn.2024.100283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/01/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Abstract
Objective We aimed to understand family preferences around reporting and receiving health-related social needs (HRSN) information by assessment modality during pediatric emergency department (PED) visits. Methods Families were randomized into paper (control), cell phone, or tablet modality groups by their child's exam room. Nurses alerted families to complete a single HRSN assessment during routine workflow. We used logistic regression and McNemar's test to assess discordance in modality preference. Results Forty-seven percent of families disclosed at least one HRSN across a total 611 assessments. Disclosure of HRSN was similar by modality. Twenty-three percent of those assigned tablet preferred cell phone (p < 0.001). Two-thirds of families preferred receiving digitally formatted community resources (email or text). There was no difference in preferred timing of HRSN assessment completion. Conclusions Assessment modality did not appear to influence family HRSN disclosure. Families were generally satisfied with all HRSN assessment modalities but demonstrated a particular preference in using personal cell phones over tablets. Digitally formatted community referrals also pose numerous advantages over conventional paper handouts. Innovation Use of personal cell phones is a novel, streamlined method of HRSN interventions in the clinical setting, performing similar to more conventional modalities, with a preference among families when compared to tablets.
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Affiliation(s)
- Raymen Rammy Assaf
- Emergency Medicine Specialists of Orange County, Children's Hospital Orange County, Orange, USA
- Department of Pediatrics, University of California, Irvine (UCI) School of Medicine, Irvine, USA
| | - Ryan David Assaf
- Benioff Homelessness and Housing Initiative, Center for Vulnerable Populations, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, USA
| | - Patricia Sencer Padlipsky
- Department of Emergency Medicine, Harbor-University of California, Los Angeles (UCLA) Medical Center, Torrance, USA
| | - Kelly Dee Ann Young
- Department of Emergency Medicine, Harbor-University of California, Los Angeles (UCLA) Medical Center, Torrance, USA
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2
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Merle JL, Carroll AJ, Mohanty N, Berkel C, Scherr C, Davis MM, Wakschlag LS, Smith JD. Pediatric clinicians' perspectives on assessing concerns about young children's social-emotional wellbeing in primary care. J Child Health Care 2024; 28:700-714. [PMID: 36916317 PMCID: PMC10500037 DOI: 10.1177/13674935231163362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
We surveyed pediatric primary care clinicians working in Federally Qualified Health Centers about their perceptions of children's social-emotional wellbeing. We identified clinician's current methods for assessing social-emotional wellbeing in practices, perceived implementation barriers to providing behavioral health care, and interest in adopting a validated, low-burden developmentally sensitive parent-report instrument for screening for social-emotional wellbeing in young children. We surveyed 72 PCCs working in FQHCs from 9 US states. Analyses included examining central tendencies, correlations, analysis of variance, and group differences via t-tests. Average PCC perceptions of social-emotional wellbeing importance for overall health were statistically significantly higher than their confidence in providing care for common social-emotional wellbeing concerns (mean difference = 1.31, 95% CI = 1.13-1.49). PCCs expressed low satisfaction with currently available screening measures for identifying concerns in social-emotional wellbeing. Fewer than half of clinicians reported using any standardized parent-reported measure for identifying concerns in social-emotional wellbeing. Assessment methods and decision tools that improve clinician confidence concerning risk indications are needed, particularly at the critical early childhood period. Policymakers and payers ought to facilitate funding mechanisms that support pediatric PCCs in identifying early concerns in social-emotional wellbeing and providing referral guidance to evidence-based interventions to support parents and caregivers.
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Affiliation(s)
- James L Merle
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA
| | - Allison J Carroll
- Departments of Psychiatry and Behavioral Sciences and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nivedita Mohanty
- AllianceChicago and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cady Berkel
- Program in Integrated Behavioral Health, College of Health Solutions, Arizona State University, Tempe, AZ, USA
| | - Courtney Scherr
- Department of Communication Studies, School of Communication, Northwestern University, Evanston, IL, USA
| | - Matthew M Davis
- Departments of Pediatrics and Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren S Wakschlag
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA
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3
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Matson PA, Calihan JB, Bagley SM, Adger H. Family-Focused Prevention and Early Intervention of Substance Use in Pediatric Primary Care Settings. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:464-473. [PMID: 39563867 PMCID: PMC11571187 DOI: 10.1176/appi.focus.20240026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2024]
Abstract
Prevention of substance misuse and substance use disorders is a national public health priority. The home environment can represent risk or protective factors for development of substance misuse. Children in homes with caregiver substance use are biologically, developmentally, interpersonally, and environmentally vulnerable to substance misuse and associated consequences, making it necessary for substance use prevention to focus on families early. Children and families who are minoritized, marginalized, and disenfranchised experience disproportionate consequences of substance use, through experiences of poverty, racism, trauma, and the built environment. Strengthening protective factors in early childhood by improving the health of caregivers and supporting the caregiver-child relationship can have enduring benefits over the life course. Pediatric primary care practices are an important setting for adopting a family-focused approach to prevention and early intervention of substance use. By engaging families early, identifying substance use in the family and household, recognizing the intersection of social needs and substance use, providing culturally tailored, trauma-informed, evidence-based care, and advising and supporting families on ways to minimize substance-related harm, pediatric care providers can play an important role in preventing substance use and substance-related consequences to children and families. Pediatric care providers are ideally suited to deliver prevention messages in a nonstigmatizing manner and serve as a conduit to evidence-based, family-focused intervention programs.
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Affiliation(s)
- Pamela A Matson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore (Matson, Adger); Department of Pediatrics (Calihan, Bagley), and Department of Medicine (Bagley), Chobanian & Avedisian School of Medicine, Boston University, Boston; Department of Pediatrics (Calihan, Bagley), and Grayken Center for Addiction (Bagley), Boston Medical Center, Boston
| | - Jessica B Calihan
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore (Matson, Adger); Department of Pediatrics (Calihan, Bagley), and Department of Medicine (Bagley), Chobanian & Avedisian School of Medicine, Boston University, Boston; Department of Pediatrics (Calihan, Bagley), and Grayken Center for Addiction (Bagley), Boston Medical Center, Boston
| | - Sarah M Bagley
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore (Matson, Adger); Department of Pediatrics (Calihan, Bagley), and Department of Medicine (Bagley), Chobanian & Avedisian School of Medicine, Boston University, Boston; Department of Pediatrics (Calihan, Bagley), and Grayken Center for Addiction (Bagley), Boston Medical Center, Boston
| | - Hoover Adger
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore (Matson, Adger); Department of Pediatrics (Calihan, Bagley), and Department of Medicine (Bagley), Chobanian & Avedisian School of Medicine, Boston University, Boston; Department of Pediatrics (Calihan, Bagley), and Grayken Center for Addiction (Bagley), Boston Medical Center, Boston
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4
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Midura D, Levano S, Fiori KP, Farber BA. Analysis of Social Determinants of Health in the Pediatric General Surgical Population of a Northeastern Urban Health System. J Pediatr Surg 2024; 59:1822-1827. [PMID: 38760308 DOI: 10.1016/j.jpedsurg.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 04/01/2024] [Accepted: 04/23/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Social determinants of health (SDOH) have been identified as factors that influence patient health outcomes. These are well described in adult and pediatric general populations, however, there is a paucity of data for surgical patients. This study compares the prevalence of health-related social needs (HRSN) among pediatric surgery and general pediatric patients. METHODS We retrospectively assessed electronic health record data to identify patients who completed a standardized HRSN screener within our health system and underwent surgery by a pediatric surgeon between January 2019 and December 2021. We compared this population to non-surgical pediatric patients during this time. Bivariate and multivariate logistic regressions were conducted to estimate the likelihood of having 1 or more HRSN given a patient's surgery status. Logistic and linear regressions were conducted to estimate healthcare utilization in pediatric surgery patients given their HRSN status. RESULTS 33,989 general pediatric and pediatric surgery patients (age <21 years) were screened for HRSNs, and 2112 operations were performed during the study period. 343 (20%) of the surgical patients operated on by pediatric surgeons were screened for HRSNs. Surgical patients were more likely to be younger, Latinx, Spanish-speaking, and non-commercially insured (p < 0.0001). Surgical patients were 50% more likely to report one or more HRSN, when adjusting for demographic characteristics (aOR 1.50, 95% CI 1.16, 1.94). CONCLUSION Pediatric surgery patients are more likely to report HRSNs compared to the general pediatric population. Surgical patients may represent an at-risk group, and universal HRSN screening and support should be considered to improve outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Devin Midura
- Department of Surgery, Division of Pediatric Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, 3355 Bainbridge Avenue, Bronx, NY 10467, USA
| | - Samantha Levano
- Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA; Department of Family & Social Medicine, Division of Research, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Kevin P Fiori
- Department of Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, 3415 Bainbridge Avenue, Bronx, NY, 10467, USA; Department of Family & Social Medicine, Division of Research, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA; Office of Community & Population Health, Montefiore Health System, 3514 DeKalb Avenue, Bronx, NY, 10467, USA
| | - Benjamin A Farber
- Department of Surgery, Division of Pediatric Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, 3355 Bainbridge Avenue, Bronx, NY 10467, USA.
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Vestal E, Newman S, Phillips S. Barriers and facilitators to accessing pediatric specialty care for rural-dwelling children with complex chronic conditions: An integrative review. J Pediatr Nurs 2024; 77:e385-e393. [PMID: 38777676 DOI: 10.1016/j.pedn.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024]
Abstract
PROBLEM Pediatric specialty services are often geographically concentrated in urban areas, leaving up to 1 in 5 rural-dwelling children in the United States without access to advanced care. The purpose of this review was to identify and review extant literature related to barriers and facilitators to accessing specialty care for rural-dwelling children with complex chronic conditions. ELIGIBILITY CRITERIA The Whittemore and Knafl (2005) integrative review method guided the review which included a critical appraisal and analysis of relevant articles published between 2012 and 2023. SAMPLE Twenty-three studies were identified for inclusion in the integrative review. RESULTS Using the domains of the Levesque et al. (2013) conceptual framework, findings were categorized according to the access to care continuum. Barriers included broadband access, transportation, and inadequate care coordination. Facilitators included telehealth, social support, and outreach clinics. CONCLUSIONS To improve access to pediatric specialty care for rural-dwelling children, nurses, physicians, and policymakers will need to consider how the social determinants of health impact the healthcare access continuum from diagnosis to continuing healthcare. IMPLICATIONS The findings of this integrative review will aid researchers in developing interventions to improve access to pediatric specialty care for rural-dwelling children.
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Affiliation(s)
- Elisabeth Vestal
- Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas Street, MSC 160 Charleston, SC 29425 United States.
| | - Susan Newman
- Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas Street, MSC 160 Charleston, SC 29425 United States
| | - Shannon Phillips
- Medical University of South Carolina, College of Nursing, 99 Jonathan Lucas Street, MSC 160 Charleston, SC 29425 United States
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Martin SR, Kain ZN. The intersection of pediatric anesthesiology and social determinants of health. Curr Opin Anaesthesiol 2024; 37:271-276. [PMID: 38441068 PMCID: PMC11042989 DOI: 10.1097/aco.0000000000001367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
PURPOSE OF REVIEW There is increasing evidence of racial and ethnic disparities in pediatric perioperative care, which indicates a need to identify factors driving disparities. Social determinants of health (SDOH) play a fundamental role in pediatric health and are recognized as key underlying mechanisms of healthcare inequities. This article summarizes recent research exploring the influence of SDOH on pediatric perioperative outcomes. RECENT FINDINGS Despite the scarcity of research exploring SDOH and pediatric perioperative outcomes, recent work demonstrates an association between SDOH and multiple outcomes across the perioperative care continuum. Measures of social disadvantage were associated with preoperative symptom severity, longer hospital stays, and higher rates of postoperative complications and mortality. In some studies, these adverse effects of social disadvantage persisted even when controlling for medical comorbidities and clinical severity. SUMMARY The existing literature offers compelling evidence of the impact of SDOH on perioperative outcomes in children and reveals a critical area in pediatric anesthesia that necessitates further exploration and action. To improve outcomes and address care inequities, future efforts should prioritize the integration of SDOH assessment into pediatric perioperative research and practice.
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Affiliation(s)
- Sarah R. Martin
- Department of Anesthesiology and Perioperative Care, University of California Irvine School of Medicine, Irvine CA
- Center on Stress & Health, University of California Irvine, Irvine, CA
- Emergency Medicine, Children’s Hospital of Orange County, Orange, CA
| | - Zeev N. Kain
- Department of Anesthesiology and Perioperative Care, University of California Irvine School of Medicine, Irvine CA
- Center on Stress & Health, University of California Irvine, Irvine, CA
- Yale University Child Study Center, New Haven, Connecticut
- Children’s Hospital of Orange County, Orange, CA
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7
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Keeton VF, Bell JF, Drake C, Fernandez Y Garcia EO, Pantell M, Hessler D, Wing H, Silveira PP, O'Donnell KJ, de Mendonça Filho EJ, Meaney MJ, Gottlieb LM. Household Social Needs, Emotional Functioning, and Stress in Low-Income Latinx Children and their Mothers. JOURNAL OF CHILD AND FAMILY STUDIES 2023; 32:796-811. [PMID: 37143480 PMCID: PMC10156014 DOI: 10.1007/s10826-023-02532-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Latinx families may be particularly vulnerable to emotional dysfunction, due to higher rates of economic hardship and complex social influences in this population. Little is known about the impact of environmental stressors such as unmet social needs and maternal stress on the emotional health of Latinx children from low-income families. We conducted secondary analyses using survey and biomarker data from 432 Latinx children and mothers collected in a separate study. We used binomial and multinomial logistic regression to test if household social needs, or maternal perceived stress or hair cortisol concentration (HCC), predicted child measures of emotional functioning or child HCC, independent of relevant sociodemographic factors. Approximately 40% of children in the sample had symptoms consistent with emotional dysfunction, and over 37% of households reported five or more social needs. High perceived maternal stress predicted higher odds of child emotional dysfunction (OR = 2.15; 95% CI [1.14, 4.04]; p = 0.01), and high maternal HCC was positively associated with high child HCC (OR = 10.60; 95% CI [4.20, 26.74]; p < 0.01). Most individual household social needs, as well as the level of household social need, were not independently associated with child emotional dysfunction or child HCC. Our findings begin to define a framework for understanding emotional health, stress, and resilience when caring for Latinx children and mothers living with high levels of social need, and the need for integrated mental health and social needs screening and interventions in settings that serve this population.
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Affiliation(s)
- Victoria F Keeton
- Corresponding Author: V.F. Keeton, University of California, San Francisco, Department of Obstetrics, Gynecology, & Reproductive Sciences, Box 2930, San Francisco, CA, USA 94143
- University of California, Davis, Betty Irene Moore School of Nursing, 2450 48 St., Sacramento, CA, USA 95817
| | - Janice F Bell
- University of California, Davis, Betty Irene Moore School of Nursing, 2450 48 St., Sacramento, CA, USA 95817
| | - Christiana Drake
- University of California, Davis, Betty Irene Moore School of Nursing, 2450 48 St., Sacramento, CA, USA 95817
- University of California, Davis, Department of Statistics, 4101 Mathematical Sciences Bldg., Davis, CA, USA 95616
| | - Erik O Fernandez Y Garcia
- University of California, Davis, Betty Irene Moore School of Nursing, 2450 48 St., Sacramento, CA, USA 95817
- University of California, Davis, Department of Pediatrics, 2521 Stockton Blvd, Suite 2200, Sacramento, CA, USA 95817
| | - Matthew Pantell
- University of California, San Francisco, Department of Pediatrics, 3333 California Street, Box 0848, San Francisco, CA, USA 94143
| | - Danielle Hessler
- University of California, San Francisco, Department of Family and Community Medicine, 500 Parnassus Ave, Box 0900, San Francisco, CA, USA 94143
| | - Holly Wing
- University of California, San Francisco, Center for Health and Community, 3333 California St., Box 0844, San Francisco, CA, USA 94143
| | - Patricia P Silveira
- Douglas Mental Health University Institute, Douglas Research Center, McGill University, 6875 Boulevard LaSalle Montreal, Québec, CA H4H1R3
- Ludmer Centre for Neuroinformatics and Mental Health and Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Kieran J O'Donnell
- Douglas Mental Health University Institute, Douglas Research Center, McGill University, 6875 Boulevard LaSalle Montreal, Québec, CA H4H1R3
- Ludmer Centre for Neuroinformatics and Mental Health and Department of Psychiatry, McGill University, Montreal, QC, Canada
- Yale Child Study Center & Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, 230 South Frontage Rd., New Haven, CT, USA 06519
| | - Euclides José de Mendonça Filho
- Douglas Mental Health University Institute, Douglas Research Center, McGill University, 6875 Boulevard LaSalle Montreal, Québec, CA H4H1R3
- Ludmer Centre for Neuroinformatics and Mental Health and Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Michael J Meaney
- Douglas Mental Health University Institute, Douglas Research Center, McGill University, 6875 Boulevard LaSalle Montreal, Québec, CA H4H1R3
- Ludmer Centre for Neuroinformatics and Mental Health and Department of Psychiatry, McGill University, Montreal, QC, Canada
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research (ASTAR), 1 Fusionopolis Way, #20-10, Singapore, Republic of Singapore 138632
| | - Laura M Gottlieb
- University of California, San Francisco, Department of Family and Community Medicine, 500 Parnassus Ave, Box 0900, San Francisco, CA, USA 94143
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Assaf RR, Assaf RD, Barber Doucet H, Graff D. Pediatric emergency department organization and social care practices among U.S. fellowship programs. AEM EDUCATION AND TRAINING 2022; 6:AET210791. [PMID: 35982713 PMCID: PMC9366751 DOI: 10.1002/aet2.10791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/26/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
Background Social care has become increasingly relevant to the emergency physician and includes activities that address health-related social risk and social needs. The literature has consistently documented substantial health care provider challenges in incorporating social care into routine practice. Yet, interventions on the health care organizational level hold promise to bring about more widespread, sustainable impact. Methods This study was a subanalysis of the 2021 National Social Care Practices Survey data set among pediatric emergency medicine (PEM) program directors (PDs) and fellows. The purpose was to investigate the association between health care organizational factors and PEM physician social care practices and perceptions among PEM PDs and fellows. We performed binary and ordinal logistic regressions of organizational factors and five specific PEM physician social care perspective and practice outcomes. Results The sample population included 153 physicians-44 PDs (49% response rate) and 109 fellows (28%). PDs and fellows with access to a social care systematic workflow in their pediatric emergency department (PED) had higher odds of comfort assessing social risk (odds ratio [OR] 2.1%, 95% confidence interval [CI] 1.1-4.0), valuation of social care (OR 3.2, 95% CI 1.3-7.9), preparedness to assist families (OR 2.4, 95% CI 1.1-5.2), screening tendency (OR 2.2, 95% CI 1.1-4.5), and ability to refer to community resources (OR 2.3, 95% CI 1.2-4.6). A similarly directed, but less pronounced pattern was noted with access to a community resource database for referrals and 24-h access to a social worker in the PED. Conclusions PED organizational factors-particularly access to a social care systematic workflow-appear positively associated with PEM physician practices and perceptions of social care delivery. Further research is under way to advance understanding of PEM training factors in social care.
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Affiliation(s)
- Raymen Rammy Assaf
- Harbor University of California Los Angeles (UCLA) Medical CenterLos AngelesCaliforniaUSA
| | | | - Hannah Barber Doucet
- Hasbro Children's HospitalAlpert Medical School at Brown UniversityProvidenceRhode IslandUSA
| | - Danielle Graff
- Norton Children's HospitalUniversity of Louisville, School of MedicineLouisvilleKentuckyUSA
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Liu PY, Beck AF, Lindau ST, Holguin M, Kahn RS, Fleegler E, Henize AW, Halfon N, Schickedanz A. A Framework for Cross-Sector Partnerships to Address Childhood Adversity and Improve Life Course Health. Pediatrics 2022; 149:e2021053509O. [PMID: 35503315 PMCID: PMC9549524 DOI: 10.1542/peds.2021-053509o] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 11/24/2022] Open
Abstract
Childhood adversity and its structural causes drive lifelong and intergenerational inequities in health and well-being. Health care systems increasingly understand the influence of childhood adversity on health outcomes but cannot treat these deep and complex issues alone. Cross-sector partnerships, which integrate health care, food support, legal, housing, and financial services among others, are becoming increasingly recognized as effective approaches address health inequities. What principles should guide the design of cross-sector partnerships that address childhood adversity and promote Life Course Health Development (LCHD)? The complex effects of childhood adversity on health development are explained by LCHD concepts, which serve as the foundation for a cross-sector partnership that optimizes lifelong health. We review the evolution of cross-sector partnerships in health care to inform the development of an LCHD-informed partnership framework geared to address childhood adversity and LCHD. This framework outlines guiding principles to direct partnerships toward life course-oriented action: (1) proactive, developmental, and longitudinal investment; (2) integration and codesign of care networks; (3) collective, community and systemic impact; and (4) equity in praxis and outcomes. Additionally, the framework articulates foundational structures necessary for implementation: (1) a shared cross-sector theory of change; (2) relational structures enabling shared leadership, trust, and learning; (3) linked data and communication platforms; and (4) alternative funding models for shared savings and prospective investment. The LCHD-informed cross-sector partnership framework presented here can be a guide for the design and implementation of cross-sector partnerships that effectively address childhood adversity and advance health equity through individual-, family-, community-, and system-level intervention.
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Affiliation(s)
- Patrick Y. Liu
- Center for Healthier Children, Families, and Communities
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Andrew F. Beck
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stacy Tessler Lindau
- Department of Obstetrics and Gynecology and The University of Chicago, Chicago, Illinois
- Section of Geriatrics and Palliative Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois
| | - Monique Holguin
- University of Southern California Suzanne Dworak-Peck School of Social Work, Los Angeles, California
| | - Robert S. Kahn
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eric Fleegler
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | | | - Neal Halfon
- Center for Healthier Children, Families, and Communities
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Adam Schickedanz
- Center for Healthier Children, Families, and Communities
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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10
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Assaf RR, Barber Doucet H, Assaf R, Graff D. Social care practices and perspectives among U.S. pediatric emergency medicine fellowship programs. AEM EDUCATION AND TRAINING 2022; 6:e10737. [PMID: 35493290 PMCID: PMC9045575 DOI: 10.1002/aet2.10737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/01/2022] [Accepted: 03/04/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND The emergence of social emergency medicine-the incorporation of social context into the structure and practice of emergency care-has brought forth greater embracement of the social determinants of health by medical professionals, yet workforce practices and training have remained elusive. Academic literature particularly in the field of pediatric emergency medicine (PEM) fellowship training is lacking relative to general pediatrics and adult emergency medicine. METHODS The primary objective of this study was to assess the social care knowledge, perspectives, and training of PEM program directors (PDs) and fellows across a national cross-sectional sample. A secondary aim was to uncover key actionable areas for the development of social care curricula in PEM training programs. A social care practices assessment tool was developed via snowball sampling interviews among clinician researcher experts and disseminated to PEM PDs and fellows nationally in accredited academic PEM training institutions. RESULTS A total of 153 participants-44 PDs (49% response rate) and 109 fellows (28%)-completed the assessment tool. Responses among PDs and fellows were highly concordant. Only 12% reported regular use of a standardized social needs screening tool. The majority felt unprepared to assist families with social needs and less than half felt comfortable talking to families about social need. At the same time, social care was highly valued by 73% of participants. All participants felt that providing social care training during PEM fellowship would be beneficial. PDs and fellows identified five priority areas for PEM curricular development. CONCLUSIONS PEM PDs and fellows have an overall favorable perception of social care yet report significant deficits in current practice organization and training. This study is part of a larger national collaborative advocacy project to organize and advance social care delivery across academic PEM training institutions through evidence-based approaches, best practices, and expert consensus.
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Affiliation(s)
- Raymen Rammy Assaf
- Harbor University of California Los Angeles (UCLA) Medical CenterTorranceCaliforniaUSA
| | - Hannah Barber Doucet
- Hasbro Children’s HospitalAlpert Medical School at Brown UniversityProvidenceRhode IslandUSA
| | | | - Danielle Graff
- School of MedicineNorton Children’s HospitalUniversity of LouisvilleLouisvilleKentuckyUSA
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11
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Dubowitz H, Finkelhor D, Zolotor A, Kleven J, Davis N. Addressing Adverse Childhood Experiences in Primary Care: Challenges and Considerations. Pediatrics 2022; 149:e2021052641. [PMID: 35362065 PMCID: PMC9405315 DOI: 10.1542/peds.2021-052641] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2021] [Indexed: 11/24/2022] Open
Abstract
This article draws attention to the overlapping literature on social determinants of health and adverse childhood experiences, and the growing clinical interest in addressing them to promote children's and parents' health and well-being. We address important considerations and suggest solutions for leaders and practitioners in primary care to address social determinants of health/adverse childhood experiences. Priorities include: begin with a few prevalent conditions for which there are helpful resources; focus on conditions that are current or recent and where parents may be more apt to engage in services; focus initially on families with children aged <6 given the frequency of well-child visits and the especially strong relationships between primary care professionals and parents during this period; ensure training of primary care professionals and staff to help them play this role competently and comfortably; and have good referral processes to facilitate additional evaluation or help.
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Affiliation(s)
- Howard Dubowitz
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - David Finkelhor
- Department of Sociology, University of New Hampshire, Durham, New Hampshire
| | - Adam Zolotor
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jennifer Kleven
- Department of Pediatrics, Gundersen Health System, La Crosse, Wisconsin
| | - Neal Davis
- Pediatric Community Based Care, Intermountain Primary Children’s Hospital, Salt Lake City, Utah
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12
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Beck AF, Henize AW, Qiu T, Huang B, Zhang Y, Klein MD, Parrish D, Fink EE, Kahn RS. Reductions In Hospitalizations Among Children Referred To A Primary Care-Based Medical-Legal Partnership. Health Aff (Millwood) 2022; 41:341-349. [PMID: 35254924 DOI: 10.1377/hlthaff.2021.00905] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Medical-legal partnerships integrate legal advocates into health care settings to address health-related social needs. However, their effect on health outcomes is unclear. This retrospective cohort study examined the effect of referral to a medical-legal partnership on hospitalization rates among urban, low-income children in Greater Cincinnati, Ohio, between 2012 and 2017. We compared 2,203 children referred to a pediatric primary care-based medical-legal partnership with 100 randomly selected control cohorts drawn from 34,235 children seen concurrently but not referred. We found that the median predicted hospitalization rate for children in the year after referral was 37.9 percent lower if children received the legal intervention than if they did not. We suspect that this decrease in hospitalizations was driven by the ability of legal advocates to address acute legal needs (for example, threat of eviction and public benefit denial) and, when possible, to confront root causes of ill health (for example, unhealthy housing conditions). Interventions such as those provided through a medical-legal partnership may be important components of integrated, value-based service delivery models.
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Affiliation(s)
- Andrew F Beck
- Andrew F. Beck , University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - TingTing Qiu
- TingTing Qiu, Cincinnati Children's Hospital Medical Center
| | - Bin Huang
- Bin Huang, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center
| | - Yin Zhang
- Yin Zhang, Cincinnati Children's Hospital Medical Center
| | - Melissa D Klein
- Melissa D. Klein, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center
| | - Donita Parrish
- Donita Parrish, Legal Aid Society of Greater Cincinnati, Cincinnati, Ohio
| | - Elaine E Fink
- Elaine E. Fink, Legal Aid Society of Greater Cincinnati
| | - Robert S Kahn
- Robert S. Kahn, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center
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13
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De Sam Lazaro SL, Riley BRW. Maximizing the use of the intraprofessional team to develop interprofessional pediatric primary care teams. J Interprof Care 2022; 35:44-48. [DOI: 10.1080/13561820.2021.1982882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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14
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Magnan S. Social Determinants of Health 201 for Health Care: Plan, Do, Study, Act. NAM Perspect 2021; 2021:202106c. [PMID: 34532697 DOI: 10.31478/202106c] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Sanne Magnan
- Health Partners Institute and the University of Minnesota
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15
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Zambrana RE, Torres-Burgos D, Carvajal DN. Expert Perspectives on Effective Community-Based Pediatric Healthcare for Low-Income Latino Families: Persistent Issues over Time. J Racial Ethn Health Disparities 2021; 9:1051-1061. [PMID: 33942249 DOI: 10.1007/s40615-021-01044-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 11/24/2022]
Abstract
US Latinos continue to experience significant health inequity, despite fluctuating healthcare policies over the past 20 years. Recent studies highlight the importance of comprehensive care and collaboration of stakeholders in reducing inequity. Few studies examine the perspectives of community-based organization leaders, health researchers, and policy experts regarding the most effective practices in the delivery of healthcare to Latino children and families. This unique study employed a mixed-methods cross-sectional design to compare perceptions of effective practices and action strategies among two groups. Analysis of qualitative data gathered from 17 organizational leaders and 28 research/policy experts resulted in four broad themes: (1) engagement of families as participants in their healthcare; (2) provision of comprehensive, family-focused healthcare services across the lifespan; (3) engagement of ethnically competent staff to provide outreach; and (4) development of community collaborations for resource building. Respondents identified three major barriers to the provision of high-quality care: (1) inequities in social determinants; (2) ongoing changes in insurance coverage; and (3) funding challenges for the support of community-based health centers (CHCs). Although the data were collected in 2001, these thematic findings remain relevant given the persistence of inequities and the lack of progress in mitigating inequity among Latino children and families, despite evolving healthcare system changes. The study conclusions reaffirm the importance of community-driven preventive healthcare services across the life course. These community services are the frontline of healthcare for many Latino children and their families; therefore, their sustainability is crucial. The voices of organizational leaders, health research, and policy experts are important and relevant.
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Affiliation(s)
- Ruth Enid Zambrana
- Harriet Tubman Department of Women, Gender and Sexuality Studies, University of Maryland, College Park, MD, 20742, USA.
| | | | - Diana N Carvajal
- Department of Family & Community Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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16
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SCHOR EDWARDL. Developing a Structure of Essential Services for a Child and Adolescent Mental Health System. Milbank Q 2021; 99:62-90. [PMID: 33463772 PMCID: PMC7984671 DOI: 10.1111/1468-0009.12490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Policy Points That child and adolescent mental health services needs are frequently unmet has been known for many decades, yet few systemic solutions have been sought and fewer have been implemented at scale. Key among the barriers to improving child and adolescent mental health services has been the lack of well-organized primary mental health care. Such care is a mutual but uncoordinated responsibility of multiple disciplines and agencies. Achieving consensus on the essential structures and processes of mental health services is a feasible first step toward creating an organized system.
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Abstract
PURPOSE OF REVIEW This review examines the current evidence about the ways in which food insecurity relates to obesity in children and adolescents, examining diet and diet-related behaviors, and taking into consideration the role of stress. RECENT FINDINGS While living with food insecurity impacts stress and diet-related behaviors in children and adolescents, it is not clear whether food insecurity is associated with obesity above and beyond the influence of poverty. However, strategies to mitigate food insecurity and obesity are inherently connected, and recent examples from clinical practice (e.g., screening for food insecurity among patients) and advocacy (e.g., policy considerations regarding federal food programs such as the Supplemental Nutrition Assistance Program, or SNAP) are discussed. Food insecurity and obesity coexist in low-income children and adolescents in the USA. The COVID-19 pandemic exerts disproportionate burden on low-income children and families, magnifying their vulnerability to both food insecurity and pediatric obesity.
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Affiliation(s)
- June M Tester
- Division of Pediatric Endocrinology, UCSF Benioff Children's Hospital Oakland, 744 52nd Street, Oakland, 94609, CA, USA.
- Department of Pediatrics, Division of Endocrinology, University of California, San Francisco, 550 16th Street, 4th Floor Box 0110, San Francisco, CA, USA.
| | - Lisa G Rosas
- Epidemiology and Population Health, Stanford University, School of Medicine, Stanford, CA, USA
| | - Cindy W Leung
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
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18
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Flower KB, Massie S, Janies K, Bassewitz JB, Coker TR, Gillespie RJ, Macias MM, Whitaker TM, Zubler J, Steinberg D, DeStigter L, Earls MF. Increasing Early Childhood Screening in Primary Care Through a Quality Improvement Collaborative. Pediatrics 2020; 146:peds.2019-2328. [PMID: 32769199 DOI: 10.1542/peds.2019-2328] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Multiple early childhood screenings are recommended, but gaps persist in implementation. Our aim for this project was to improve screening, discussion, referral, and follow-up of development, autism spectrum disorder (ASD), maternal depression, and social determinants of health (SDoH) to 90% by July 2018. METHODS This 1-year national quality improvement collaborative involved 19 pediatric primary care practices. Supported by virtual and in-person learning opportunities, practice teams implemented changes to early childhood screening. Monthly chart reviews were used to assess screening, discussion, referral, and follow-up for development, ASD, maternal depression, and SDoH. Parent surveys were used to assess parent-reported screening and referral and/or resource provision. Practice self-ratings and team surveys were used to assess practice-level changes. RESULTS Participating practices included independent, academic, hospital-affiliated, and multispecialty group practices and community health centers in 12 states. The collaborative met development and ASD screening goals of >90%. Largest increases in screening occurred for maternal depression (27% to 87%; +222%; P < .001) and SDoH (26% to 76%; +231%; P < .001). Statistically significant increases in discussion of results occurred for all screening areas. For referral, significant increases were seen for development (53% to 86%; P < .001) and maternal depression (23% to 100%; P = .008). Parents also reported increased screening and referral and/or resource provision. Practice-level changes included improved systems to support screening. CONCLUSIONS Practices successfully implemented multiple screenings and demonstrated improvement in subsequent discussion, referral, and follow-up steps. Continued advocacy for adequate resources to support referral and follow-up is needed to translate increased screening into improved health outcomes.
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Affiliation(s)
- Kori B Flower
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; .,Population Health Improvement Partners, Cary, North Carolina
| | - Sara Massie
- Population Health Improvement Partners, Cary, North Carolina
| | | | | | - Tumaini R Coker
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Research Institute, Seattle, Washington
| | | | - Michelle M Macias
- Division of Developmental-Behavioral Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Toni M Whitaker
- Division of Developmental Pediatrics, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jennifer Zubler
- Learn the Signs. Act Early Program, Division of Birth Defects, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia; and
| | | | | | - Marian F Earls
- Community Care of North Carolina, Raleigh, North Carolina
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19
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Disparities Affect Developmental Risk for Head Start Preschoolers. J Pediatr Nurs 2020; 54:86-92. [PMID: 32682249 DOI: 10.1016/j.pedn.2020.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 05/16/2020] [Accepted: 06/21/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE This paper presents an analysis of Head Start (HStart) preschooler data by severity of developmental concern, while considering socio-demographic and other factors that highlight racial and ethnic disparities in the early identification of developmental delay or disability (DD). DESIGN AND METHODS We conducted an analysis of 2014-2015 academic year data for preschool-aged children in HStart in both urban and suburban centers in a large Midwestern city. Descriptive statistics were used to determine the prevalence of developmental concerns and compare characteristics of children with mild-to-moderate versus severe developmental concerns; differences between groups were compared using t-tests and chi-square tests. Multivariate logistic regression was used to determine the independent effect of each predictor of concern severity. RESULTS Nearly one-third of HStart preschoolers were identified with developmental concern; 70% were mild-to-moderate risk for DD and the remaining severe risk. Neither group was routinely referred to healthcare for evaluation or treatment, and most of the severe risk group did not qualify nor receive treatment for DD with an Individualized Education Plan. Suburban and urban preschoolers with severe concern were less likely to be African American or Latinx, suggesting that racially and ethnically diverse preschoolers in HStart may be under-identified and under-treated. CONCLUSIONS Lags in the educational diagnosis of DD may mirror the disparities in diagnosis and treatment of DD among minority groups. Primary care is the first line for detection and treatment of DD, and offers a unique opportunity to act for racially and ethnically diverse HStart preschoolers disproportionately at-risk for DD.
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20
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Stiles-Shields C, Potthoff LM, Bounds DT, Burns MTS, Draxler JM, Otwell CH, Wolodiger ED, Westrick J, Karnik NS. Harnessing Phones to Target Pediatric Populations with Socially Complex Needs: Systematic Review. JMIR Pediatr Parent 2020; 3:e19269. [PMID: 32845244 PMCID: PMC7481873 DOI: 10.2196/19269] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/20/2020] [Accepted: 08/11/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Mobile and smartphones are owned and accessed by many, making them a potentially optimal delivery mechanism to reach pediatric patients with socially complex needs (ie, pediatric populations who face overlapping adversities). OBJECTIVE To address the specialized needs of youth from such groups, this review synthesized the literature exploring the use of phone-based delivery to access pediatric populations with socially complex needs, targeting mental and behavioral health outcomes. The purpose of this synthesis was to provide recommendations for future research developing phone-based interventions for youth with socially complex needs. METHODS A trained medical librarian conducted the search strategy in the following databases: PubMed, Scopus, CINAHL, PsycINFO, Cochrane CENTRAL Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Studies targeting youth with socially complex needs were defined by recruiting samples that were primarily from traditionally underserved populations (ie, sex/gender minorities, racial/ethnic background, low socioeconomic status, rural/remote location, and sexual orientation). A systematic narrative framework was utilized and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed (registration number CRD42020141212). RESULTS A total of 14 studies met the inclusion criteria, with 3 depicting the use of phones to complete assessment and tracking goals and 11 to intervene on mental and behavioral health targets. CONCLUSIONS The literature indicates important directions for future research, including (1) involving diverse and representative teens (ie, the likely users of the interventions), stakeholders, and clinical/research staff; (2) integrating evidence-based therapies with minority-focused theories; (3) harnessing mobile device capabilities; and (4) considering and assessing for potential costs in phones as delivery mechanisms. TRIAL REGISTRATION PROSPERO CRD42020141212; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=141212.
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Affiliation(s)
- Colleen Stiles-Shields
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Lauren M Potthoff
- Department of Gastroenterology, Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Dawn T Bounds
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA, United States
| | | | - Janel M Draxler
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Caitlin H Otwell
- Autism Assessment, Research, Treatment & Services Center, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Emily D Wolodiger
- Autism Assessment, Research, Treatment & Services Center, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
| | - Jennifer Westrick
- Library of Rush University Medical Center, Chicago, IL, United States
| | - Niranjan S Karnik
- Section of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States
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21
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Beck AF, Edwards EM, Horbar JD, Howell EA, McCormick MC, Pursley DM. The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families. Pediatr Res 2020; 87:227-234. [PMID: 31357209 PMCID: PMC6960093 DOI: 10.1038/s41390-019-0513-6] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/04/2019] [Indexed: 02/06/2023]
Abstract
Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.
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Affiliation(s)
- Andrew F Beck
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of General & Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, VT, USA.
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA.
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, University of Vermont, Burlington, VT, USA.
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT, USA
- Department of Pediatrics, Robert Larner, MD, College of Medicine, University of Vermont, Burlington, VT, USA
| | - Elizabeth A Howell
- Blavatnik Family Women's Health Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marie C McCormick
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - DeWayne M Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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22
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Power-Hays A, Li S, Mensah A, Sobota A. Universal screening for social determinants of health in pediatric sickle cell disease: A quality-improvement initiative. Pediatr Blood Cancer 2020; 67:e28006. [PMID: 31571379 PMCID: PMC6868301 DOI: 10.1002/pbc.28006] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Social determinants of health (SDoH) are socioeconomic factors that influence health outcomes. Guidelines recommend universal screening for SDoH at clinic visits; however, models that do not require additional resources are limited in subspecialty clinics. Individuals with sickle cell disease (SCD) face the burdens of chronic illness and often racial disparities, both of which may increase their vulnerability to adverse SDoH. Hematologists can impact both quality of life and clinical outcomes for their patients by implementing screening and referral programs addressing SDoH. METHODS Through prospective, quality-improvement methods, we introduced universal screening for SDoH into our pediatric hematology clinic. The intervention was a paper screener followed by a referral to local community organizations for the specific needs endorsed. The aims of this study were to determine the feasibility of universal screening for SDoH in a busy subspeciality clinic using pre-existing resources to identify the needs of our patients and to facilitate referrals between our patients and community organizations via this low touch intervention. RESULTS Between August 2017 and November 2018, 156 screens were completed. Sixty-six percent were positive for at least one unmet social need for which 80% were referred to a relevant community organization. Forty-five percent of patients available via follow-up phone call reached out to the community organization. CONCLUSIONS There is a high burden of SDoH in families of children with SCD. Universal screening at a pediatric hematology clinic with the subsequent connection of patients with SCD to community resources is feasible using existing clinic resources.
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Affiliation(s)
| | | | | | - Amy Sobota
- Boston Medical Center, Department of Pediatrics
- Boston University School of Medicine
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23
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Goldhagen JL, Shenoda S, Oberg C, Mercer R, Kadir A, Raman S, Waterston T, Spencer NJ. Rights, justice, and equity: a global agenda for child health and wellbeing. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 4:80-90. [PMID: 31757760 DOI: 10.1016/s2352-4642(19)30346-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 11/16/2022]
Abstract
Worldwide challenges to child health and wellbeing are rapidly becoming existential threats to children and childhood. Inequities, armed conflict and violence, nuclear proliferation, forced migration, globalisation, and climate change are among the global issues violating children's rights to optimal survival and development. Child rights-based approaches will be required to enhance the response to the civil-political, social, economic, and cultural determinants of these global child health issues. In this Viewpoint, we present a global agenda for child health and wellbeing as a blueprint for the practice of paediatrics and child health in the domains of clinical care, systems development, and policy formulation. This global agenda is grounded in the principles of rights, justice, and equity and can address the root-cause determinants of health. The 30th anniversary of the UN Convention on the Rights of the Child is a relevant moment to recommit to shared goals for children's health and wellbeing.
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Affiliation(s)
| | | | - Charles Oberg
- University of Minnesota, Divisions of Global Pediatrics and Epidemiology & Community Health, Minneapolis, MN, USA
| | - Raúl Mercer
- Program of Social Sciences and Health, Facultad Latinoamericana de Ciencias Sociales (FLASCO), Buenos Aires, Argentina
| | - Ayesha Kadir
- Department of Paediatrics, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | - Shanti Raman
- Department of Community Paediatrics, Sydney and South Western Sydney Local Health Districts, Liverpool, NSW, Australia
| | - Tony Waterston
- Institute of Child Health and Society, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Nicholas J Spencer
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
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Goyal NK, Brown CM, Folger AT, Hall ES, Van Ginkel JB, Ammerman RT. Adherence to Well-Child Care and Home Visiting Enrollment Associated with Increased Emergency Department Utilization. Matern Child Health J 2019; 24:73-81. [DOI: 10.1007/s10995-019-02821-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Hughes-Reid C. Commentary: Pediatric Primary Care Psychology: 40 Years of Addressing Gaps in Healthcare. J Pediatr Psychol 2019; 44:882-884. [DOI: 10.1093/jpepsy/jsz057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/23/2019] [Accepted: 06/13/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Cheyenne Hughes-Reid
- Nemours A.I. duPont Hospital for Children, Sidney Kimmel Medical College, Thomas Jefferson University
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Marie-Mitchell A, Kostolansky R. A Systematic Review of Trials to Improve Child Outcomes Associated With Adverse Childhood Experiences. Am J Prev Med 2019; 56:756-764. [PMID: 30905481 DOI: 10.1016/j.amepre.2018.11.030] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 11/29/2022]
Abstract
CONTEXT The purpose of this systematic literature review was to summarize current evidence from RCTs for the efficacy of interventions involving pediatric health care to prevent poor outcomes associated with adverse childhood experiences measured in childhood (C-ACEs). EVIDENCE ACQUISITION On January 18, 2018, investigators searched PubMed, PsycInfo, SocIndex, Web of Science, Cochrane, and reference lists for English language RCTs involving pediatric health care and published between January 1, 1990, and December 31, 2017. Studies were included if they were (1) an RCT, (2) on a pediatric population, and (3) recruited or screened based on exposure to C-ACEs. Investigators extracted data about the study sample and recruitment strategy, C-ACEs, intervention and control conditions, intermediate and child outcomes, and significant associations reported. EVIDENCE SYNTHESIS A total of 22 articles describing results of 20 RCTs were included. Parent mental illness/depression was the most common C-ACE measured, followed by parent alcohol or drug abuse, and domestic violence. Most interventions combined parenting education, social service referrals, and social support for families of children aged 0-5years. Five of six studies that directly involved pediatric primary care practices improved outcomes, including three trials that involved screening for C-ACEs. Eight of 15 studies that measured child health outcomes, and 15 of 17 studies that assessed the parent-child relationship, demonstrated improvement. CONCLUSIONS Multicomponent interventions that utilize professionals to provide parenting education, mental health counseling, social service referrals, or social support can reduce the impact of C-ACEs on child behavioral/mental health problems and improve the parent-child relationship for children aged 0-5years.
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Affiliation(s)
- Ariane Marie-Mitchell
- Departments of Preventive Medicine and Pediatrics, Loma Linda University, Loma Linda, California.
| | - Rashel Kostolansky
- Claremont Graduate University,School of Community and Global Health, Claremont, California
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Zand DH, Pierce KJ, Ladage J, Heaney MS, Sallee HM. I Get By With A Little Help From My Friends: Models of Psychological Intervention in Pediatric Primary Care. MISSOURI MEDICINE 2019; 116:111-116. [PMID: 31040496 PMCID: PMC6461326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The pediatric primary care setting is ideal for addressing children's and adolescents' mental health needs. As a result of extensive training in health promotion, consultation, assessment, and treatment of psychological disorders, psychologists are uniquely positioned to support primary care pediatricians in this endeavor. This paper provides a review of models of psychology interventions in pediatric primary care including: care delivery, scope of practice, implementation and recent research. It concludes with a case example and recommendations.
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Affiliation(s)
- Debra H Zand
- Debra H. Zand, PhD, Professor, Saint Louis University Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Katherine J Pierce
- Katherine J. Pierce, PhD, Research Coordinator, Saint Louis University, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Jennifer Ladage
- Jennifer Ladage, MD, Associate Professor, Saint Louis University Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Mary S Heaney
- Mary S. Heaney, MD, MPH, Professor, Saint Louis University Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Heidi M Sallee
- Heidi M. Sallee, MD, Associate Professor, Saint Louis University Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
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Steinberg JR, Ramphos E, Bruce JS, Chamberlain LJ. What Do Clinical Environments Say to Our Patients? A Replicable Model for Creative Advocacy. Am J Public Health 2018; 108:1509-1510. [DOI: 10.2105/ajph.2018.304678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jecca R. Steinberg
- Jecca R. Steinberg is with the Stanford School of Medicine, Stanford, CA. Eleni Ramphos is with the Mayview Community Health Center, Palo Alto, CA. Janine S. Bruce and Lisa J. Chamberlain are with the Department of Pediatrics, Stanford University School of Medicine, Stanford
| | - Eleni Ramphos
- Jecca R. Steinberg is with the Stanford School of Medicine, Stanford, CA. Eleni Ramphos is with the Mayview Community Health Center, Palo Alto, CA. Janine S. Bruce and Lisa J. Chamberlain are with the Department of Pediatrics, Stanford University School of Medicine, Stanford
| | - Janine S. Bruce
- Jecca R. Steinberg is with the Stanford School of Medicine, Stanford, CA. Eleni Ramphos is with the Mayview Community Health Center, Palo Alto, CA. Janine S. Bruce and Lisa J. Chamberlain are with the Department of Pediatrics, Stanford University School of Medicine, Stanford
| | - Lisa J. Chamberlain
- Jecca R. Steinberg is with the Stanford School of Medicine, Stanford, CA. Eleni Ramphos is with the Mayview Community Health Center, Palo Alto, CA. Janine S. Bruce and Lisa J. Chamberlain are with the Department of Pediatrics, Stanford University School of Medicine, Stanford
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Jaganath D, Johnson K, Tschudy MM, Topel K, Stackhouse B, Solomon BS. Desirability of Clinic-Based Financial Services in Urban Pediatric Primary Care. J Pediatr 2018; 202:285-290. [PMID: 30029865 DOI: 10.1016/j.jpeds.2018.05.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 05/01/2018] [Accepted: 05/31/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To determine the desirability of integrating financial services in pediatric primary care among caregivers and older adolescents. STUDY DESIGN We conducted a cross-sectional study among caregivers and late adolescents 18 years and older attending an urban, pediatric primary care clinic. RESULTS The 221 participants had a mean age of 32.1 years, with 28% of the sample aged 18-25 years. The majority were African American (90.1%), female (83.3%), and single parents (55.1%). More than one-third of the participants (35.8%) reported no household earned income, and 26.7% had a yearly household total income of <$12,000. More than one-half (61.5%) reported financial stress in general, and 67.9% believed that the clinic should provide financial services, including financial education and job workshops. A greater proportion of those who desired clinic-based services were African American (94.7% vs 75%; P < .001) and had a low or middle subjective social status (95.7% vs 83.7%; P = .01). CONCLUSIONS Clinic-based financial services are desired by caregivers and late adolescents in an urban pediatric primary care practice. Prospective studies are needed to assess the long-term impact of integrated services on childhood poverty and family well-being.
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Affiliation(s)
- Devan Jaganath
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD; Division of Pediatric Infectious Diseases, Department of Pediatrics, University of California San Francisco School of Medicine, San Francisco, CA.
| | - Karl Johnson
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Megan M Tschudy
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Brian Stackhouse
- Biostatistics, Epidemiology and Data Management (BEAD) Core, Center for Child and Community Health Research, Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Barry S Solomon
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
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Stripping the Wallpaper of Practice: Empowering Social Workers to Tackle Poverty. SOCIAL SCIENCES-BASEL 2018. [DOI: 10.3390/socsci7100193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The relationship between deprivation and health and educational inequalities has been well evidenced in the literature. Recent UK research has now established a similar social gradient in child welfare interventions (Bywaters et al. 2018) with children living in the most deprived areas in the UK facing a much higher chance of being placed on the child protection register or in out-of-home care. There is an emerging narrative that poverty has become the wallpaper of practice, “too big to tackle and too familiar to notice” (Morris et al. 2018) and invisible amid lack of public support and political will to increase welfare spending. This paper will examine poverty-related inequalities and how these affect families. It will discuss the importance of recognising that poverty is a social justice issue and a core task for social work and outline the range of supports that may be available for families to help lift them out of poverty. Finally, it will describe the development of a new practice framework for social work in Northern Ireland that challenges social workers to embed anti-poverty approaches in their practice. The framework emphasises that poverty is a social justice issue, seeks to provide practical support and guidance to re-focus attention, debate, and action on poverty in times of global economic uncertainty and give social workers the tools to make it central to their practice once again. It reinforces the need for social workers to understand and acknowledge the impact of poverty, and to advocate for and support those most in need. It aims to challenge and empower professionals to tackle poverty and inequality as an aspect of ethical and effective practice.
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Federico SG, Cull W, Olson L, Garg A, Racine AD, Fisher A, Dreyer B. United States Pediatricians' Attitudes Regarding Public Policies for Low-Income Children and Their Profession's Advocacy Priorities. Acad Pediatr 2018; 18:783-788. [PMID: 29654906 DOI: 10.1016/j.acap.2018.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 03/22/2018] [Accepted: 04/05/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To examine pediatricians' attitudes toward public policies for low-income children and the advocacy efforts for the American Academy of Pediatrics (AAP). METHODS Data from the AAP Periodic Survey in October 2014 to March 2015 were used. Respondents ranked 1) attitudes toward government programs, and 2) attitudes toward AAP policies on: income support, housing, education, job training, food, and health care. Results were analyzed according to age, gender, practice location, practice region, type of practice setting, and percent of patients with economic hardship. RESULTS Response rate was 47% (n = 650). Most respondents reported that for children, the government should guarantee health insurance (88.9%), and food and shelter (90.0%). Most also reported that the government should guarantee health insurance (68.9%) and food and shelter (63.9%) for every citizen and to take care of people who cannot take care of themselves. There was variation among the level of support on the basis of practice setting. In multivariable analyses related to supporting the role of government for children and citizens, not being from the Northeast was associated with lower odds of support of children as well as citizens; primary care practices in rural areas were less supportive of government involvement related to all citizens but similar for children; and those younger than 40 and 50 to 59 years of age were more supportive of government guaranteeing enough to eat and a place to sleep for children. More than 55% supported the AAP advocating for income support, housing, education, and access to health care. CONCLUSIONS Pediatricians strongly support government policies that affect child poverty and the provision of basic needs to families. This support should be used to inform professional organizations, advocates, and policy-makers focused on children and families.
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Affiliation(s)
- Steven G Federico
- Denver Health, Department of General Pediatrics, Denver, CO; University of Colorado at Denver-Anschutz Medical Campus, General Pediatrics, Aurora, CO.
| | - William Cull
- American Academy of Pediatrics, Department of Practice and Research, Itasca, IL
| | - Lynn Olson
- American Academy of Pediatrics, Department of Practice and Research, Itasca, IL
| | - Arvin Garg
- Boston University School of Medicine/Boston Medical Center, Department of General Pediatrics, Boston, MA
| | - Andrew D Racine
- Montefiore Health System and Albert Einstein College of Medicine, Pediatrics, Bronx, NY
| | - Amanda Fisher
- American Academy of Pediatrics, Department of Practice and Research, Itasca, IL
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Duke NN, Borowsky IW. Adverse childhood experiences: Evidence for screening beyond preventive visits. CHILD ABUSE & NEGLECT 2018; 81:380-388. [PMID: 29803147 DOI: 10.1016/j.chiabu.2018.05.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 05/13/2018] [Accepted: 05/14/2018] [Indexed: 05/28/2023]
Abstract
Primary efforts to screen for adverse childhood experiences (ACE/ACEs) are often focused on the well child/adolescent visit. The purpose of this study was to examine relationships between ACEs and youth likelihood of receiving preventive care. Data are from 126,868 students in the 8th, 9th, and 11th grades who participated in the 2016 Minnesota Student Survey, an anonymous, self-report questionnaire examining youth behaviors, experiences, and perceptions. Logistic regression models were used to determine if 10 types of ACEs, including abuse, household dysfunction, and food and housing insecurity were associated with receipt of recommended preventive medical and dental care after adjustment for demographic covariates and self-reported health. ACEs scores were entered into regression models to test for cumulative impact of adversities on preventive care outcomes. More than one third (38.5%) of youth identified at least one ACE, most commonly having a parent or guardian who had ever been in jail or prison. Each type of ACE was significantly associated with reduced odds of receiving preventive care in the last year. Associations with food insecurity were of greatest magnitude, associated with 0.32 [CI: 0.64-0.72] to 0.54 [CI: 0.44-0.49] decreased odds of receiving care. Each one point increase in the total ACE score was associated with 0.07 [CI: 0.92-0.94] to 0.15 [CI: 0.84-0.86] decreased odds of having had a preventive care visit in the last year. Findings add to the growing literature documenting significant relationships between ACEs and health, in this case, youth missing opportunities to receive recommended surveillance and anticipatory guidance.
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Affiliation(s)
- Naomi N Duke
- Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, 717 Delaware St SE, # 385, Minneapolis, MN, USA.
| | - Iris W Borowsky
- Division of General Pediatrics and Adolescent Health, Department of Pediatrics, University of Minnesota, 717 Delaware St SE, # 389, Minneapolis, MN, USA.
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Abstract
OBJECTIVE School readiness by kindergarten entry is associated with increased high school graduation, decreased juvenile arrest, and better long-term health. Inadequate early childhood learning (ECL) disproportionately affects low-income children. Pediatricians have near-universal access to children younger than 5 years but remain an underused ECL resource. This study examined caregivers' perceptions of ECL, the role of the pediatrician and pediatric office, and the use of community-based ECL resources among diverse, low-income caregivers whose children were not enrolled in preschool. METHODS Using community-engaged strategies, caregivers were recruited to participate in in-depth focus groups (FGs). Demographic and FG data were collected in English, Spanish, and Vietnamese. Qualitative data were analyzed with iterative transcript-based coding and theme analysis. RESULTS From June 2015 to August 2015, 69 low-income mothers (n = 46), fathers (n = 8), and grandparents (n = 15) from African-American (33%), Latino (32%), and Vietnamese (35%) communities participated in 12 FGs. Caregivers across groups wanted pediatricians to act as ECL experts and to provide ECL services. Caregivers valued ECL, especially when delivered by trusted sources. Utilization and perception of community ECL resources varied among groups. The greatest variation included different preferences for resource setting, accessibility, and acceptability, especially cultural acceptability. Each individual and groups' unique, and occasionally adverse, experiences and financial and logistical considerations informed ECL preferences. CONCLUSION This exploratory study brings forth diverse caregivers' perspectives regarding the role of pediatricians in ECL and their desire for pediatricians to be an access point for high-quality, affordable ECL services. Caregivers' preferences regarding ECL programming may inform clinic-based pediatric ECL programming.
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Starr MC, Fisher K, Thompson K, Thurber-Smith K, Hingorani S. A pilot investigation of food insecurity among children seen in an outpatient pediatric nephrology clinic. Prev Med Rep 2018; 10:113-116. [PMID: 29850396 PMCID: PMC5966523 DOI: 10.1016/j.pmedr.2018.02.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 02/26/2018] [Accepted: 02/28/2018] [Indexed: 11/18/2022] Open
Abstract
Food insecurity (FI) is common - affecting one in six American households with children. FI is defined as limited or uncertain availability of nutritionally adequate and safe foods. Awareness of food insecurity and its impact on health has increased since the American Academy of Pediatrics 2015 policy statement, “Promoting Food Security for All Children.” Though FI is frequently addressed in general pediatric primary care, it is not routinely identified in patients with chronic medical problems. Patients with complex care needs, prescription medication, or restrictive nutritional requirements may be at higher risk of food insecurity. The prevalence of FI in patients with chronic disease, including pediatric patients with kidney disease, remains unknown. We sought to determine the prevalence of FI among our pediatric nephrology clinic patients with a cross-sectional screening pilot study. Nearly 35% of 118 children seen in our pediatric nephrology outpatient clinic lived in food insecure households, a prevalence rate more than double the general pediatric population (16%). Barriers to food security were variable; common themes included challenges with restricted diet and available food, identifying and accessing community resources, and not qualifying for support. For physicians, dietitians, and other health providers that counsel patients with kidney disease on dietary interventions, it is important to be aware of food security status. To our knowledge, this is the first study to assess the prevalence of food insecurity in pediatric patients with kidney disease. Further studies of food insecurity and social determinants of heath in this patient population are needed. Food insecurity affects more than 1 in 6 American children. Food insecurity results in worse health outcomes in those with chronic disease. In a pediatric nephrology clinic, nearly one third of patients were food insecure. Families reported challenges with restricted diet and finding community resources.
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Affiliation(s)
- Michelle C. Starr
- Department of Pediatrics, Division of Nephrology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
- Corresponding author at: University of Washington/Seattle Children's Hospital, 4800 Sand Point Way NE, OC.9.830, Seattle, WA 98105, USA.
| | - Kelly Fisher
- Department of Pediatrics, Division of Child Psychiatry, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Kirsten Thompson
- Department of Pediatrics, Division of Nephrology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Kathryn Thurber-Smith
- Department of Pediatrics, Division of Nephrology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Sangeeta Hingorani
- Department of Pediatrics, Division of Nephrology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
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The primary care provider and the patient living in poverty: Applying the Bridges to Health and Healthcare model to NP practice. J Am Assoc Nurse Pract 2018; 30:201-207. [PMID: 29757788 DOI: 10.1097/jxx.0000000000000036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE There is a much recent emphasis on the social determinants of health, and poverty is the most influential of these. It is not enough merely to understand the influence of poverty on health-the primary care provider must understand how to effectively treat patients who live in poverty. METHODS This article applies the Bridges to Health and Healthcare model for understanding poverty to primary care practice from an individual provider's perspective. The article walks the reader through the implications of generational poverty for the primary care clinician in a typical office visit from history taking to following up. CONCLUSIONS Most primary care practitioners approach patients from a middle-class perspective. Awareness of the challenges and different perspectives of those in generational poverty can enhance care and outcomes. IMPLICATIONS FOR PRACTICE The individual provider can use the understanding of driving forces, resources, language and cognition, environment, and relationships provided by the Bridges to Health and Healthcare model to benefit patients in generational poverty.
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Palakshappa D, Skelton JA. What a Summer Nutrition Benefit Program Could Mean for Clinicians and Their Patients. Pediatrics 2018; 141:peds.2017-2701. [PMID: 29592870 DOI: 10.1542/peds.2017-2701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Deepak Palakshappa
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Joseph A Skelton
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
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Transformation of a Pediatric Primary Care Waiting Room: Creating a Bridge to Community Resources. Matern Child Health J 2018. [PMID: 29525916 DOI: 10.1007/s10995-018-2508-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Introduction Children and families living in poverty frequently encounter social risks that significantly affect their health and well-being. Physicians' near universal access to at-risk children and their parents presents opportunities to address social risks, but time constraints frequently interfere. We sought to redesign our waiting room to create a clinic-to-community bridge and evaluate the impact of that redesign on family-centered outcomes. Methods We conducted a pre-post study of a waiting room redesign at a large, academic pediatric primary care center. Design experts sought input about an optimal waiting room from families, community partners and medical providers. Family caregivers were surveyed before and after redesign regarding perceived availability of help with social needs and access to community resources, and hospitality and feelings of stress. Pre-post differences were assessed using the Chi square or Wilcoxon rank sum test. Results The key redesign concepts that emerged included linkages to community organizations, a welcoming environment, and positive distractions for children. A total of 313 caregiver surveys were completed (pre-160; post-153). Compared to pre-redesign, caregivers surveyed post-redesign were significantly more likely to perceive the waiting room as a place to obtain help connecting to community resources and find information about clinical and educational resources (both p < 0.05). Families were also significantly more likely to report the waiting room as more welcoming and relaxing, with sufficient privacy and space (all p < 0.05). Discussion Waiting rooms, typically a place of wasted time and space, can be redesigned to enhance families' engagement and connection to community resources.
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Young DR, Koebnick C, Hsu JWY. Sociodemographic associations of 4-year overweight and obese incidence among a racially diverse cohort of healthy weight 18-year-olds. Pediatr Obes 2017; 12:502-510. [PMID: 27560930 DOI: 10.1111/ijpo.12173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 06/20/2016] [Accepted: 06/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emerging adulthood is a critical time for excess weight gain. Risk can be masked if recommended overweight and obesity cut-points for Asians are not employed. OBJECTIVES To determine the associations among sociodemographic factors and occurrence of overweight and obesity among normal weight 18-year olds. METHODS Normal weight (body mass index < 25 kg m-2 ; <23 kg m-2 for Asians) 18-year-old (9037 boys, 13 786 girls, 36% Hispanic, 34% non-Hispanic Whites, 10% Black, 5% Asian) members of a healthcare organization in 2008 were followed through 2012 to identify incidence of overweight and obesity. Hazard ratios (HR) and 95% confidence intervals (CI) were determined controlling for sex, race/ethnicity, neighbourhood education, neighbourhood income and smoking status. RESULTS After 3 years of follow-up, the HR for overweight was 1.28 (95% CI: 1.12, 1.45) in the lowest quartile of neighbourhood education compared with the highest. Asians and Pacific Islanders had greater risk of overweight (HR 2.89, 95% CI: 2.55, 3.28; HR 3.13, 95% CI 2.23, 4.38) than non-Hispanic Whites. Girls and Blacks were more likely to become obese than boys and non-Hispanic Whites, as were those living in the lowest neighbourhood education quartile and lower neighbourhood income quartiles. CONCLUSIONS Girls, Asians, Blacks and those living in low education and income neighbourhoods during adolescence are at risk for excessive weight gain trajectories.
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Affiliation(s)
- D R Young
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - C Koebnick
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - J-W Y Hsu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
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Morone J. An Integrative Review of Social Determinants of Health Assessment and Screening Tools Used in Pediatrics. J Pediatr Nurs 2017; 37:22-28. [PMID: 28811057 PMCID: PMC5865646 DOI: 10.1016/j.pedn.2017.08.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 07/10/2017] [Accepted: 08/07/2017] [Indexed: 11/19/2022]
Abstract
PROBLEM Social and physical contexts which make up social determinants of health (SDOH) have tremendous impacts on youth development, health and well-being. Despite knowledge and evidence of these impacts, few pediatric SDOH screening tools are known. The purpose of this review was to identify and evaluate available pediatric SDOH screening tools. ELIGIBILITY CRITERIA Articles were limited to studies in the English language, with pediatric populations, conducted in the United States, and were peer-reviewed, primary studies. SAMPLE Search of 3 databases (PsychInfo, CINAHL and PubMed) yielded 499 articles, 486 were excluded. Total of 13 articles were appraised and synthesized using the SDOH framework outlined by Healthy People 2020. RESULTS Thirteen articles relevant to the assessment of SDOH domains were evaluated. Majority of studies were limited in both the number of SDOH domains screened and the depth of screening. Tools were heterogeneous in methods used to assess SDOH risks and few were validated. Limited number of studies included youth or families in the initial development of tools. CONCLUSIONS Despite growing recognition across healthcare that SDOH greatly influence pediatric health risks, management and outcomes, there is a dearth of available high quality, multidimensional, comprehensive screening tools for pediatric care professionals. IMPLICATIONS This review emphasizes the need for the continued development of effective, comprehensive and practical tools for assessing pediatric SDOH risk factors. Pediatric nursing care includes the assessment of the youth and family context to effectively evaluate resource needs. Pediatric nurses are well poised to address this knowledge and resource gap.
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Affiliation(s)
- Jennifer Morone
- University of Pennsylvania - School of Nursing, Philadelphia, PA, United States.
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Wissow LS, Brown JD, Hilt RJ, Sarvet BD. Evaluating Integrated Mental Health Care Programs for Children and Youth. Child Adolesc Psychiatr Clin N Am 2017; 26:795-814. [PMID: 28916015 DOI: 10.1016/j.chc.2017.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Evaluations of integrated care programs share many characteristics of evaluations of other complex health system interventions. However, evaluating integrated care for child and adolescent mental health poses special challenges that stem from the broad range of social, emotional, and developmental problems that need to be addressed; the need to integrate care for other family members; and the lack of evidence-based interventions already adapted for primary care settings. Integrated care programs for children's mental health need to adapt and learn on the fly, so that evaluations may best be viewed through the lens of continuous quality improvement rather than evaluations of fixed programs.
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Affiliation(s)
- Lawrence S Wissow
- Division of Child and Adolescent Psychiatry, Johns Hopkins School of Medicine, 550 North Broadway, Room 949, Baltimore, MD 21205, USA.
| | - Jonathan D Brown
- Mathematica Policy Research, 1100 1st Street, NE 12th Floor, Washington, DC 20024-2512, USA
| | - Robert J Hilt
- Department of Psychiatry and Behavioral Sciences, University of Washington, M/S CPH, PO Box 5371, Seattle, WA 98105, USA
| | - Barry D Sarvet
- Department of Psychiatry, University of Massachusetts, Medical School at Baystate, 759 Chestnut Street, WG703, Springfield, MA 01199, USA
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Brown JD, King MA, Wissow LS. The Central Role of Relationships With Trauma-Informed Integrated Care for Children and Youth. Acad Pediatr 2017; 17:S94-S101. [PMID: 28185977 DOI: 10.1016/j.acap.2017.01.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/30/2016] [Accepted: 01/21/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Primary care plays an essential role in the primary and secondary prevention of children's mental health problems. A growing series of trials have shown the capacity of primary care providers to deliver care that specifically addresses risks to healthy social and emotional development by incorporating mental health services into their routines and integrating their work with the mental health care system. In this article elements common to various integration schemes that seem essential to their success are described. METHODS Narrative review, combining conclusions from 3 previous systematic reviews. RESULTS Trusting, personal relationships between patients and providers, and among collaborating providers, are a critical element of successful trauma-informed integrated care. Patient-provider relationships are essential to disclosure of sensitive concerns, to engaging patients in care, and to designing care that is responsive to individual patient needs. Studies of patient-centered care and psychotherapy suggest ways that these relationships can be built and maintained. Provider-provider relationships are, in turn, essential to coordinating the work of the range of providers and services needed to address trauma prevention and treatment. These relationships can form within a variety of organizational structures but building them might require staff training, redesign of work flows, and support from organizational structures and goals. CONCLUSIONS A variety of interventions at the patient-provider, clinical site, system, and policy levels can foster relationships and provide the foundation for care capable of addressing promotion of social and emotional well-being in general and trauma prevention and treatment in particular.
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Affiliation(s)
| | - Melissa A King
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md
| | - Lawrence S Wissow
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; Division of Child and Adolescent Psychiatry, Johns Hopkins School of Medicine, Baltimore, Md.
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O'Malley D, Woods-Jaeger BA, Dowd MD. Building a Collaboration Between a Children's Hospital and an Early Childhood Education and Social Services Center. Curr Probl Pediatr Adolesc Health Care 2017; 47:222-228. [PMID: 28826807 DOI: 10.1016/j.cppeds.2017.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
To address toxic stress among children growing up in poverty, an innovative collaboration was developed between a community center, Operation Breakthrough (OB), and a tertiary care children's hospital, Children's Mercy Hospital (CMH). OB started as a day care center but has expanded and developed ways to provide shelter, safety, food, employment, education and health care. CMH is a traditional academic children's hospital that, in recent years, has been looking for ways to better address the social determinants of health. This article describes how the two organizations found ways to work together to capitalize on each other's strengths. Although the two institutions shared some common goals, they had very different organizational structure. We describe how a series of complex negotiations and trust-building exercises eventually led to a robust and unique partnership.
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Affiliation(s)
- Donna O'Malley
- Department of Social Work, Children's Mercy Hospital, Kansas City, MO
| | - Briana A Woods-Jaeger
- Department of Social Work, Children's Mercy Hospital, Kansas City, MO; Division of Developmental and Behavioral Pediatrics, University of Missouri, Kansas City (UMKC) School of Medicine, Kansas City, MO
| | - M Denise Dowd
- Division of Emergency Medicine, Associate Director Office for Faculty Development Medical, Director of Community Programs, Department of Social Work, Children's Mercy, Kansas City, Professor of Pediatrics, UMKC School of Medicine, Kansas City, MO
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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: 50] [Impact Index Per Article: 7.1] [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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Palakshappa D, Vasan A, Khan S, Seifu L, Feudtner C, Fiks AG. Clinicians' Perceptions of Screening for Food Insecurity in Suburban Pediatric Practice. Pediatrics 2017. [PMID: 28634247 DOI: 10.1542/peds.2017-0319] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND National organizations recommend pediatricians screen for food insecurity (FI). Although there has been growing research in urban practices, little research has addressed FI screening in suburban practices. We evaluated the feasibility, acceptability, and impact of screening in suburban practices. METHODS We conducted a mixed methods study that implemented FI screening in 6 suburban pediatric primary care practices. We included all children presenting for either a 2-, 15-, or 36-month well-child visit (N = 5645). Families who screened positive were eligible to be referred to our community partner that worked to connect families to the Supplemental Nutrition Assistance Program. We conducted focus groups with clinicians to determine their perceptions of screening and suggestions for improvement. RESULTS Of the 5645 children eligible, 4371 (77.4%) were screened, of which 122 (2.8%) screened positive for FI (range: 0.9%-5.9% across practices). Of the 122 food-insecure families, only 1 received new Supplemental Nutrition Assistance Program benefits. In focus groups, 3 themes emerged: (1) Time and workflow were not barriers to screening, but concerns about embarrassing families and being unable to provide adequate resources were; (2) Clinicians reported that parents felt the screening showed caring, which reinforced clinicians' continued screening; (3) Clinicians suggested implementing screening before the visit. CONCLUSIONS We found it is feasible and acceptable for clinicians to screen for FI in suburban practices, but the referral method used in this study was ineffective in assisting families in obtaining benefits. Better approaches to connect families to local resources may be needed to maximize the effectiveness of screening in suburban settings.
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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
| | | | - 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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Affiliation(s)
- Lawrence S Wissow
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
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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: 101] [Impact Index Per Article: 12.6] [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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