The Impact of Community Engagement in the Design and Implementation of the Flint Registry.

BACKGROUND: The Flint water crisis (FWC) was a public health tragedy caused by crumbling infrastructure, subverted democracy, and indifference toward a predominantly poor and Black community that resulted in lead-in-water exposure, Legionnaires' disease, and emotional and health-related trauma. Through the cooperation of community partners, the Flint Registry (FR) was conceived to track long-term health and improve public health via service connections. OBJECTIVES: This study sought to share the FR's community-partnered, multi-tiered engagement strategy and determine the efficacy of this strategy to engage the community and reach Flint residents. METHODS: Community engagement and impact were measured by collecting and describing feedback from the community engagement strategies and by comparing the demographics of the enrollees recruited through community-engaged recruitment (CER) and non-CER methods. Enroll-ees indicated how they heard about the FR; CER involved direct interaction with a community member. RESULTS: Community engagement strategies incorporated approximately 1,200 people and 7 funded organizations, impacting 22 key areas of FR design and implementation. More than 50% of enrollees heard about the FR through CER methods. They were, on average, more likely to be younger, female, Black/African American, and living outside of Flint during the FWC. CONCLUSIONS: Community engagement elevated voices of those impacted by the FWC. CER methods were as effective as non-CER methods. Although there were no differences in screened measures of social vulnerability, there were in age, gender, and race. CER methods may increase participation and build trust in populations which historically are hesitant to participate in public health efforts.

REDCap to Epic interfaces create an efficient hybrid software solution for a public health registry.

A public health registry and intervention was created in response to the Flint water crisis to identify and refer exposed individuals to public health services to ameliorate the deleterious impact of lead exposure. Traditional technology architecture domains, funded scope of work, as well as community input were considered when defining the requirements of the selected solutions. A hybrid software solution was created using Research Electronic Data Capture (REDCap) to deploy an open participant survey and bypass requirements to create user accounts, and Epic to manage deduplication and participant communication and tracking. To bridge the two software systems, REDCap to Epic unidirectional ADT and Documentation Flowsheet interfaces were built to automate creation of subject records in Epic identical to those created in REDCap and to copy key protocol-driving variables from REDCap to Epic. The interfaces were critical to deliver a successful hybrid solution in which the desired features of each software could be leveraged to satisfy specific protocol requirements and community input. Data from the start of survey administration (December 2018) through 31 December 2020 are reported to demonstrate the usefulness of the interfaces.

Child Mental Health Status in Flint, Michigan: A Worsening Health Inequity, 2018-2022.

Objectives. To determine the burden of mental health disorders among children enrolled in Michigan's Flint Registry in the context of a local public health crisis and a nationally declared pediatric mental health crisis. Methods. This survey-based study included 1203 children aged 3 to 17 years whose caregivers enrolled them in the Flint Registry between December 2018 and March 2020 and who completed a follow-up survey between October 2020 and March 2022. The baseline and follow-up surveys included caregiver reports of childhood anxiety and depression and overall mental health wellness. Results. At enrollment, Flint Registry caregivers reported significantly higher rates of anxiety and depression among their children than caregivers reported nationally (12.9% vs 9.4% and 8.2% vs 4.4%; P < .001). Flint Registry caregivers also reported declines in their children's overall mental health wellness at follow-up, t(1472) = -4.17; P < .001. Conclusions. Our findings reveal a disparate burden of pediatric mental health disorders and exemplify the health inequities vulnerable populations face. Public Health Implications. More proactive and preventive steps should be taken to lessen this burden, especially in chronically disadvantaged communities that experience public health crises. (Am J Public Health. 2023;113(12):1318-1321. https://doi.org/10.2105/AJPH.2023.307406).

Removing Michigan's Lead Water Service Lines: Economic Savings, Health Benefits, And Improved Health Equity.

Michigan's recently revised Lead and Copper Rule requires water utilities to inventory existing water service lines by 2025 and replace all lead-containing lines by 2041. This article summarizes a cost-benefit analysis using new inventory data on the number of lead service lines in the state, the projected cost of their replacement, and the estimated lifetime benefits from reduced lead exposure. Replacing 423,479 lead service lines would reduce lead exposure for 420,800 newborns and result in $3.24 billion in future benefits (compared with replacement costs of $1.33 billion). This would generate net savings of $1.91 billion and a societal return on investment of $2.44 per dollar invested. These estimates are conservative and include only quantified benefits for newborn children in Michigan for the period 2020-60. More than 153,100 of the children benefiting would be non-White (of whom 78,400 would be Black or African American), and 106,900 would be in households with incomes below the federal poverty level. Sensitivity analyses show that accelerating the replacement pace would increase the societal return on investment. This primary prevention-driven policy has the potential to reduce childhood lead exposure and improve health equity.

"The Shelves Are Bare": The Impact of COVID-19 on Families Enrolled in a Pediatric Produce Prescription Program.

Objectives A large pediatric clinic in Flint, Michigan, implemented a produce prescription program for youth to address enduring challenges with food access and food insecurity. Approximately 18 months later, on March 23, 2020, the State of Michigan issued a "stay home, stay safe" executive order in response to the COVID-19 pandemic. This study sought to (1) explore caregiver experiences with access to and utilization of the prescription program during COVID-19; and (2) understand perceived changes in the food environment during the "stay home, stay safe" executive order. Methods Researchers collected data through recorded, semi-structured telephone interviews with caregivers of children who received at least one produce prescription and had previously enrolled in a preliminary effectiveness study on the prescription program. We transcribed the recordings verbatim for textual analysis. Examining the qualitative data using thematic analysis, we identified patterns across transcripts and formulated illustrative themes. Results Fifty-six caregivers (mean age, 41.3 ± 10.3 years) participated in interviews. The majority were female (91%), African American (70%), and Flint residents (75%). Recurrent themes, each centered around changes in the food environment resulting from COVID-19, emerged: (1) produce prescription access and utilization; (2) food access constraints; (3) food shopping adjustments; and (4) food insecurity stress. Perceived consequences of COVID-19 included increased anxiety related to food shopping and food insecurity alongside challenges accessing and utilizing the produce prescription program. Conclusions This study highlights the many ramifications of the COVID-19 pandemic on vulnerable families. More comprehensive efforts are necessary to address substantial barriers to healthy food access and affordability caused by the recent pandemic.

Parent report of child behaviour: Findings from the Flint Registry cohort.

BACKGROUND: Children in Flint, Michigan, have multiple risk factors for behavioural challenges, including exposure to lead during the Flint water crisis. However, their behavioural health status is largely unknown. Robust data from the Flint Registry can help understand the burden of behavioural outcomes and inform the allocation of resources. OBJECTIVES: This population-level evaluation of Flint children's behavioural outcomes aims to answer the question: What is the burden of parent-reported child behaviour problems in Flint Registry enrolled children? METHODS: This cross-sectional study describes parent-reported behavioural outcomes of children 2-17 years old who enrolled in the Flint Registry between December 2018 and December 2020. Parents/guardians completed behavioural assessments including the Behavior Assessment System for Children (BASC-3) Parent Rating Scale and Behavior Rating Inventory of Executive Function (BRIEF2) Screening Parent Form. Demographics of enrolees were compared with census data. Composite BASC-3 T scores were compared with national norms. Distributions for clinically relevant categories of BASC-3 and BRIEF2 scores were examined across age and sex groups. RESULTS: Of the 3579 children included in this study (mean age 9.73 ± 3.96 years), about half were female and 79.7% were eligible for free or reduced-price lunch. Almost half of the children were reported to have clinically concerning scores on the BASC-3 Parent Rating Scale (44.7%) and the BRIEF2 Screening Parent Form (46.7%). Across most age and sex groupings, the reported adaptive skills were relatively low and behaviour symptoms relatively high. CONCLUSIONS: Results reveal a substantial burden of parent-reported behavioural problems in Flint Registry children. This is clinically significant and indicates that a large number of children may require comprehensive neuropsychological evaluation and potential medical and/or educational services. Recognising the potential for long-term manifestations of childhood exposures to environmental hazards, longitudinal surveillance is critical to continue to identify and support participants.

Effect of a pediatric fruit and vegetable prescription program on child dietary patterns, food security, and weight status: a study protocol.

BACKGROUND: Although nutrients in fruits and vegetables are necessary for proper development and disease prevention, most US children consume fewer servings than recommended. Prescriptions for fruits and vegetables, written by physicians to exchange for fresh produce, address access and affordability challenges while emphasizing the vital role of diet in health promotion and disease prevention. Michigan's first fruit and vegetable prescription program (FVPP) exclusively for children was introduced in 2016 at one large pediatric clinic in Flint and expanded to a second clinic in 2018. The program provides one $15 prescription for fresh produce to all pediatric patients at every office visit. Prescriptions are redeemable at a year-round farmers' market or a local mobile market. The current study will assess the impact of this FVPP on diet, food security, and weight status of youth. METHODS: Demographically similar pediatric patient groups with varying levels of exposure to the FVPP at baseline will be compared: high exposure (> 24 months), moderate exposure (12-24 months), and no previous exposure. Data collection will focus on youth ages 8-16 years. A total of 700 caregiver-child dyads (one caregiver and one child per household) will be enrolled in the study, with approximately 200 dyads at clinic 1 (high exposure); 200 dyads at clinic 2 (moderate exposure), and 300 dyads at clinic 3 (no previous exposure). Children with no previous exposure will be introduced to the FVPP, and changes in diet, food security, and weight status will be tracked over two years. Specific aims are to (1) compare baseline diet, food security, and weight status between pediatric patients with varying levels of exposure to the FVPP; (2) measure changes in diet, food security, and weight status before and after never-before-exposed children are introduced to the FVPP; and (3) compare mean 12- and 24-month follow-up measures of diet, food security, and weight status in the initial no exposure group to baseline measures in the high exposure group. DISCUSSION: Completion of study aims will provide evidence for the effectiveness of pediatric FVPPs and insights regarding the duration and intensity of exposure necessary to influence change. TRIAL REGISTRATION: The study was registered through clinicaltrials.gov [ID: NCT04767282] on February 23, 2021.

Household Supplemental Nutrition Assistance Program Participation is Associated With Higher Fruit and Vegetable Consumption.

OBJECTIVE: Examine whether differences were present by Supplemental Nutrition Assistance Program (SNAP) participation in dietary patterns, achievement of dietary recommendations, and food security for children (aged 7-18 years) receiving free/reduced-price school meals. METHODS: Cross-sectional study. Caregiver-child dyads at a pediatric clinic completed validated surveys. Food security, dietary patterns, and achievement of dietary recommendations were compared between child SNAP participants/nonparticipants. RESULTS: Among 205 caregivers, 128 (62.4%) reported SNAP participation. Percentages of child SNAP participants/nonparticipants meeting recommendations were largely nonsignificantly different and overwhelmingly low. Supplemental Nutrition Assistance Program participants reported higher mean daily servings of vegetables (P = 0.01) and fruits (P = 0.01) than nonparticipants. Caregiver-reported household food security was not significantly different between SNAP participants and nonparticipants (P = 0.44). CONCLUSIONS AND IMPLICATIONS: In this study, child-reported fruit/vegetable intakes were significantly higher among SNAP participants than nonparticipants, suggesting child SNAP participants may experience small but noteworthy benefits related to fruit/vegetable consumption. Additional supports are needed to achieve dietary recommendations.

Neurodevelopmental profiles of preschool-age children in Flint, Michigan: a latent profile analysis.

OBJECTIVE: Children in Flint, Michigan, have experienced myriad sociodemographic adversities exacerbated by the Flint water crisis. To help inform child-focused prevention and intervention efforts, we aimed to describe patterns of neurodevelopmental outcomes among preschoolers who experienced the Flint water crisis before age 2 years. METHOD: Participants were 170 preschoolers who completed a comprehensive neurodevelopmental assessment battery, including directly administered measures of cognitive and executive functioning and maternal-report of adaptive skills and behavioral problems. We used latent profile analysis to derive subgroups. Multivariate multinomial logistic regression was conducted to examine the predictors of profile memberships, including child sex and maternal/family-level factors selected from an array of measured exposures using least absolute shrinkage and selection operator regression. RESULTS: Three latent profiles were identified: Profile 1-relative weakness in all domains (50%); Profile 2-normative functioning in all domains (34.1%); and Profile 3-relative strengths in executive function and behavior (15.9%). Profile 1 showed lower scores across cognitive and behavioral domains. Profile 2 demonstrated abilities within the normal range across domains. Profile 3 showed relative strength in executive functioning with few behavior problems, despite lower cognitive performance. Children across all profiles showed adaptive behavior in the adequate range. Child sex and maternal IQ were significant predictors of profile membership. CONCLUSIONS: Children in Flint demonstrated diverse patterns of development in the face of sociodemographic and environmental adversities. Comprehensive screening and neurodevelopmental profiling of children in this at-risk population are needed to identify areas of needs and inform appropriate service delivery.

Adaptive Behavior as an Alternative Outcome to Intelligence Quotient in Studies of Children at Risk: A Study of Preschool-Aged Children in Flint, MI, USA.

Intelligence quotient (IQ) is commonly measured in child development studies, while adaptive behavior is less frequently considered. Given its associations with functional outcomes in children with neurodevelopmental disabilities, adaptive behavior may be a useful outcome in general population samples, as well. This study aimed to compare social and environmental correlates of adaptive behavior vs. IQ in a sample of preschoolers exposed to the Flint water crisis (N = 184). Mother-child dyads were recruited from the community and administered a comprehensive battery to obtain information about child neurodevelopmental functioning, including direct assessment of IQ via the Wechsler Preschool and Primary Scale of Intelligence and assessment of parent-reported adaptive functioning via the Vineland Adaptive Behavior Scales. Multiple social environmental factors were explored as potential correlates of child outcomes (i.e., IQ and adaptive behavior), and robust correlates were identified using a data-driven approach [i.e., least absolute shrinkage and selection operator (LASSO) regression]. We then examined associations between the LASSO-selected predictors and IQ and adaptive behavior while controlling for child age, child sex, and maternal age. Children in this sample showed relative strength in adaptive behaviors, with scores in the adequate range, while average IQs fell in the low-average range. Adaptive behavior was significantly associated with maternal nurturance practices, while IQ was associated with the maternal education level. Implications for the use of adaptive behavior as an outcome measure in studies of children at an increased risk for neurodevelopmental problems are discussed.

Influence of a Pediatric Fruit and Vegetable Prescription Program on Child Dietary Patterns and Food Security.

Limited access to fresh foods is a barrier to adequate consumption of fruits and vegetables among youth, particularly in low-income communities. The current study sought to examine preliminary effectiveness of a fruit and vegetable prescription program (FVPP), which provided one USD 15 prescription to pediatric patients during office visits. The central hypothesis was that exposure to this FVPP is associated with improvements in dietary patterns and food security. This non-controlled longitudinal intervention trial included a sample of caregiver-child dyads at one urban pediatric clinic who were exposed to the FVPP for 1 year. Patients received one USD 15 prescription for fresh produce during appointments. A consecutive sample of caregivers whose children were 8-18 years of age were invited to participate in the study. Dyads separately completed surveys that evaluated food security and dietary behaviors prior to receipt of their first prescription and again at 12 months. A total of 122 dyads completed surveys at baseline and 12-month follow-up. Approximately half of youth were female (52%), and most were African American (63%). Mean caregiver-reported household food security improved from baseline to 12 months (p < 0.001), as did mean child-reported food security (p = 0.01). Additionally, child-reported intake of vegetables (p = 0.001), whole grains (p = 0.001), fiber (p = 0.008), and dairy (p < 0.001) improved after 12 months of exposure to the FVPP. This study provides evidence that pediatric FVPPs may positively influence food security and the dietary patterns of children.

Family Perceptions of a Cooking and Nutrition Program for Low-Income Children and Adolescents.

Background. Flint Kids Cook, a nutrition and culinary program for children and adolescents, was created in October 2017 to address health concerns among youth and families in a low-income, urban community. In this study, researchers examined family experiences with the 6-week, chef-led program, which was taught in a farmers' market kitchen. Methods. At the conclusion of each session, researchers used an open-ended focus group format to assess program experiences, perceived impact on youth self-efficacy for cooking and healthy eating, and caregiver support. This qualitative study was guided by thematic analysis. Results. Between November 2017 and December 2018, 72 caregivers (n = 38) and students (n = 34) participated in separate focus groups. Caregivers were primarily female (74%) and African American (71%). Most students were African American (76%) and half were female. Recurrent themes included food acceptance, dietary modifications, confidence in the kitchen, and program design. Caregivers and students agreed that location and design of the program alongside facilitation by an experienced chef were important factors for program success. Conclusions. This study demonstrated that a chef-led healthy cooking program for youth was effective in improving perceived food acceptance, dietary habits, and confidence in the kitchen. The program could be modeled in similar communities to address diet and health of children and adolescents.

Umbilical Cord Blood Lead Level Disparities between Flint and Detroit.

OBJECTIVE: The lead-in-water impact of the Flint water crisis on the youngest and most neurodevelopmentally vulnerable population was largely unknown. The objective of this study was to investigate and compare cord blood lead levels (CBLLs) in newborns in Flint, Michigan, after the Flint water crisis, to a group of Detroit newborns. STUDY DESIGN: Mothers of 99 Flint newborns were surveyed about potential lead exposures. These neonates were born after the recognition of population-wide lead-in-water contamination. CBLLs were measured and maternal-fetal metrics were reviewed. CBLLs and maternal-fetal metrics were then compared with those of a retrospective cohort of 116 Detroit newborns who previously shared the same water source. Analysis involved descriptive statistics, independent t-test, and χ 2 analysis. RESULTS: CBLLs greater than or equal to 1 µg/dL (0.05 µmol/L) were more prevalent among Flint newborns (14%), as compared with Detroit newborns (2%; p = 0.001). This was a sevenfold disparity between Flint and Detroit newborns. No statistically significant differences were found in birth weight, head circumference, small for gestational age status, gestational age, or preterm status among the two groups. CONCLUSION: The Flint water crisis potentially exposed newborns to lead in utero, implicating maternal-fetal outcomes and future health and development. Primary prevention efforts, including identification and mitigation of lead exposure before conception and during pregnancy, are needed. New environmental exposure detection methods and long-term neurodevelopmental follow-up will complement the findings of this study.

Preexisting Conditions That Kill Us.

To protect human life, science and public health need to guide public policy. We call for an end to the anti-science, anti-prevention, and anti-regulatory policies that have resulted in countless preexisting conditions and deaths. Reactive responses are not a substitute for primary prevention; we must invest in environmental and public health protections.

Flint Kids Cook: positive influence of a farmers' market cooking and nutrition programme on health-related quality of life of US children in a low-income, urban community.

OBJECTIVE: To examine changes in health-related quality of life (HRQoL) among youth who participated in Flint Kids Cook, a 6-week healthy cooking programme for children, and assess whether changes in HRQoL were associated with changes in cooking self-efficacy, attitude towards cooking (ATC) and diet. DESIGN: Pre-post survey (Pediatric Quality of Life Inventory, Block Kids Food Screener, 8-item cooking self-efficacy, 6-item ATC) using child self-report at baseline and programme exit. Analysis involved paired sample t-tests and Pearson's correlations. SETTING: Farmers' market in Flint, Michigan, USA. PARTICIPANTS: Children (n 186; 55·9 % female, 72·6 % African American) participated in Flint Kids Cook from October 2017 to February 2020 (mean age 10·55 ± 1·83 years; range 8-15). RESULTS: Mean HRQoL summary score improved (P < 0·001) from baseline (77·22 ± 14·27) to programme exit (81·62 ± 14·43), as did mean psychosocial health summary score (74·68 ± 15·68 v. 79·04 ± 16·46, P = 0·001). Similarly, physical (P = 0·016), emotional (P = 0·002), social (P = 0·037), and school functioning (P = 0·002) improved. There was a correlation between change in HRQoL summary score and change in ATC (r = -0·194, P = 0·025) as well as change in cooking self-efficacy (r = -0·234, P = 0·008). Changes in HRQoL and psychosocial health summary scores were not correlated with dietary changes, which included decreased added sugar (P = 0·019) and fruit juice (P = 0·004) intake. CONCLUSIONS: This study is the first to report modest yet significant improvements in HRQoL among children and adolescents who participated in a healthy cooking programme. Results suggest that cooking programmes for youth may provide important psychosocial health benefits that are unrelated to dietary changes.

Participation in a Fruit and Vegetable Prescription Program for Pediatric Patients is Positively Associated with Farmers' Market Shopping.

Objectives: The primary objective was to investigate the association between participation in a farmers' market fruit and vegetable prescription program (FVPP) for pediatric patients and farmers' market shopping. Methods: This survey-based cross-sectional study assessed data from a convenience sample of 157 caregivers at an urban pediatric clinic co-located with a farmers' market. Prescription redemption was restricted to the farmers' market. Data were examined using chi-square analysis and independent samples t-tests. Results: Approximately 65% of respondents participated in the FVPP. Those who received one or more prescriptions were significantly more likely to shop at the farmers' market during the previous month when compared to those who never received a prescription (p = 0.005). Conclusions: This is the first study to demonstrate that participation in a FVPP for pediatric patients is positively associated with farmers' market shopping.