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AIM: To determine the frequency, type, clinical, and sociodemographic associations of unmet social needs in children with cerebral palsy (CP). METHOD: We conducted a cross-sectional study of parents and carers of children with CP attending a specialist hospital clinic between July and September 2022. Unmet social needs were self-identified using a survey, guided by the WE CARE survey instrument and adapted to the local context. Sociodemographic and clinical data were obtained from medical records. We performed descriptive analysis of participants' unmet social needs, sociodemographic factors, and clinical factors, and examined for associations using a χ2 test and logistic regression. RESULTS: A total of 105 parents and carers completed the survey. Of these, 68 (64.8%) reported one or more unmet social need, with 24 (22.9%) reporting three or more unmet needs. A higher number (three or more) of unmet needs was associated with Gross Motor Function Classification System levels IV and V (odds ratio [OR] = 3.77, 95% confidence interval [CI] = 1.44-9.86) and intellectual disability (OR = 4.63, 95% CI = 1.61-13.31), but were not significant when corrected for neighbourhood socioeconomic disadvantage. The greatest socioeconomic disadvantage was associated with housing concerns (p = 0.002), food (p = 0.026), and financial insecurity (p = 0.02). INTERPRETATION: Unmet social needs are experienced by most families of children with CP. This study highlights the importance of systematic pathways to identify and address unmet social needs.
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OBJECTIVES: To assess racial and ethnic minority parents' perceptions about barriers to well-child visit attendance. METHODS: For this cross-sectional qualitative study, we recruited parents of pediatric primary care patients who were overdue for a well-child visit from the largest safety net healthcare organization in central Massachusetts to participate in semi-structured interviews. The interviews focused on understanding potential knowledge, structural, and experiential barriers for well-child visit attendance. Interview content was inductively coded and directed content analysis was performed to identify themes. RESULTS: Twenty-five racial and ethnic minority parents participated; 17 (68%) of whom identified Spanish as a primary language spoken at home. Nearly all participants identified the purpose, significance, and value of well-child visits. Structural barriers were most cited as challenges to attending well-child visits, including parking, transportation, language, appointment availability, and work/other competing priorities. While language emerged as a distinct barrier, it also exacerbated some of the structural barriers identified. Experiential barriers were cited less commonly than structural barriers and included interactions with office staff, racial/ethnic discrimination, appointment reminders, methods of communication, wait time, and interactions with providers. CONCLUSIONS: Racial and ethnic minority parents recognize the value of well-child visits; however, they commonly encounter structural barriers that limit access to care. Furthermore, a non-English primary language compounds the impact of these structural barriers. Understanding these barriers is important to inform health system policies to enhance access and delivery of pediatric care with a lens toward reducing racial and ethnic-based inequities.
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Minorías Étnicas y Raciales , Padres , Investigación Cualitativa , Humanos , Femenino , Masculino , Estudios Transversales , Padres/psicología , Adulto , Niño , Accesibilidad a los Servicios de Salud , Massachusetts , Barreras de Comunicación , Preescolar , Servicios de Salud del Niño , Persona de Mediana Edad , Entrevistas como Asunto , Etnicidad/psicologíaRESUMEN
BACKGROUND: Social determinants of health (SDoH), including access to care, economic stability, neighborhood factors, and social context, strongly influence pediatric asthma outcomes. School-supervised asthma therapy (SST) is an evidence-based strategy that improves asthma outcomes, particularly for historically marginalized children, by providing support for daily medication adherence in school. However, little is known about the relationship between these programs and the adverse SDoH commonly affecting underrepresented minority and marginalized children with asthma. METHODS: We examined qualitative data from interviews (n = 52) conducted between 2017 and 2020 with diverse multi-level partners involved in Asthma Link, a SST intervention. Participants included end-users (children and their parents), deliverers (school nurses and pediatric providers), and systems-level partners (e.g., insurers, legislators, and state officials). We used inductive coding to determine themes and subthemes and deductive coding using the Healthy People 2030 SDoH framework. RESULTS: Three themes emerged: (1) SST mitigates adverse SDoH (improves access to preventive healthcare and asthma health literacy), (2) SST benefits children experiencing specific adverse SDoH (provides a consistent medication routine to children with unstable family/housing situations) and (3) specific adverse SDoH impede SST implementation (economic instability, culture and language barriers). CONCLUSION: This study suggests an important relationship between SDoH and SST that warrants further evaluation in our future work on this community-based asthma intervention. Moreover, our findings underscore the importance of measuring SDoH in the implementation and evaluation of pediatric asthma interventions, particularly given the strong influence of these social factors on child health outcomes.
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OBJECTIVE: Examine associations between time spent in academic activities perceived as meaningful and professional well-being among academic pediatrics faculty. METHODS: The sample comprised 248 full-time pediatric faculty (76% female, 81% white, non-Hispanic, 41% instructor or assistant professor) across the United States who completed an online survey in November 2019. Survey items included sociodemographic and professional characteristics, professional well-being measures (Stanford Professional Fulfillment Index; Maslach Burnout Inventory; Intention to Leave Academic Medicine), perceived meaningfulness of academic activities and assigned time to those activities. We defined global career fit as total percentage time assigned to professional activities considered meaningful by individuals, and activity-specific career fit as percentage time assigned to each meaningful professional activity. RESULTS: As global career fit scores increased, professional fulfillment increased (r = 0.45, P < .001), whereas burnout (r = -0.29, P < .001) and intention to leave (r = -0.22, P < .001) decreased. Regarding activity-specific career fit, for individuals who considered patient care meaningful, as assigned time to patient care increased, professional fulfillment decreased (r = -0.14, P = .048) and burnout (r = 0.16, P = .02) and intention to leave (r = 0.26, P < .001) increased. There was no significant correlation between assigned time for teaching, research, or advocacy and professional well-being. Faculty were less likely to intend to leave academic medicine as assigned time increased for administrative or leadership activities if considered meaningful (r = -0.24, P = .01). CONCLUSIONS: Time assigned to meaningful work activities may relate to professional well-being of academic pediatrics faculty. More time assigned to patient care, despite being meaningful, was associated with poor self-reported professional well-being. Effort allocation among diverse academic activities needs to be optimized to improve faculty well-being.
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Agotamiento Profesional , Docentes Médicos , Satisfacción en el Trabajo , Pediatras , Humanos , Femenino , Estados Unidos/epidemiología , Masculino , Docentes Médicos/psicología , Agotamiento Profesional/epidemiología , Agotamiento Profesional/psicología , Pediatras/psicología , Adulto , Pediatría , Persona de Mediana Edad , Encuestas y CuestionariosRESUMEN
BACKGROUND: The COVID-19 pandemic posed numerous obstacles to psychosocial wellbeing for children. We conducted a longitudinal study to evaluate child mental health and social risks during the pandemic. METHODS: Participants were 172 caregivers of children aged 6-11 years old who attended well child visits within 6 months before pandemic onset at an urban safety net hospital in the US. Prepandemic data was extracted from the electronic medical record, and surveys were administered at three time points between August 2020 and July 2021. We measured mental health symptoms with the Pediatric Symptom Checklist-17, social risks (e.g., food and housing insecurity) with the THRIVE questionnaire, and school modality (in-person, hybrid, remote). RESULTS: Compared to pre-pandemic, children had significantly higher PSC-17 total scores (overall mental health symptoms) and THRIVE total scores (total burden of social risks) at all three mid-pandemic waves. Using longitudinal mixed models accounting for time, social risks, and school modality, both social risks (B = 0.37, SE = 0.14, p < 0.01) and school modality were significantly associated with PSC-17 scores (B = - 1.95, SE = 0.63, p < 0.01). Children attending in-person school had fewer mental health symptoms than those attending remote or hybrid school. CONCLUSION: Mental health symptoms and social risks remained significantly higher fifteen months after the onset of the COVID-19 pandemic compared to prepandemic. In-person attendance at school appeared protective against persistently elevated mental health symptoms.
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OBJECTIVES: To evaluate the impact of implementing a stakeholder-informed social risk screening and social service referral system in a community hospital setting. METHODS: We implemented a stakeholder-informed social care program at a community hospital in April 2022. The evaluation included patients aged 0 to 17 years admitted to the pediatric unit between April 2021 and March 2022 (1 year preimplementation) and between April 2022 and March 2023 (1 year postimplementation). For a random subset of 232 preimplementation and 218 postimplementation patients, we performed manual data extraction, documenting program process measures and preliminary effectiveness outcomes. We used χ square and Wilcoxon rank tests to compare outcomes between the preimplementation and postimplementation groups. Multivariable logistic regression was used to assess the preliminary effectiveness of the social care program in identifying social risks. RESULTS: Screening rates were higher in the postimplementation group for nearly all social domains. Compared with preimplementation, the postimplementation group had higher rates of social risks identified (17.4% vs 7.8% [P < .01]: adjusted odds ratio 2.9 [95% confidence interval 1.5-5.5]) on multivariate testing. Social work consults were completed more frequently and earlier for the postimplementation group (13.8.% vs 5.6% [P < .01]) and median (19 hours vs 25 hours [P = .03]), respectively. Rates of communication of social risks in discharge summaries were higher in the postimplementation group (46.8% vs 8.2% [P < .001]). CONCLUSIONS: The implementation of a stakeholder-informed social care program within a community hospital setting led to the increased identification of social risks and social work consultations and improved timeliness of social work consultations and written communication of social risks in discharge summaries for primary care providers.
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Hospitales Comunitarios , Pacientes Internos , Humanos , Niño , Hospitalización , Derivación y Consulta , Apoyo SocialRESUMEN
BACKGROUND: Growing evidence linking social determinants of health (SDOH) to child health outcomes has prompted widespread recommendations for pediatricians to screen and refer for adverse SDOH at primary care visits. Yet there is little evidence to date demonstrating the effectiveness of practice-based SDOH screening and referral interventions on increasing family engagement with resources. This hybrid type 2 effectiveness-implementation trial aims to demonstrate the non-inferiority of a low-touch implementation strategy in order to facilitate dissemination of an existing SDOH screening and referral system (WE CARE) and demonstrate its effectiveness and sustainability in various pediatric practices. METHODS: We recruited eighteen pediatric practices in fourteen US states through two pediatric practice-based research networks. For this stepped wedge cluster RCT, practices serve as their own controls during the Usual Care phase and implement WE CARE during the intervention phase via one of two randomized implementation strategies: self-directed, pre-recorded webinar vs. study team-facilitated, live webinar. We collect data at practice, clinician/staff, and parent levels to assess outcomes grounded in the Proctor Conceptual Model of Implementation Research. We use generalized mixed effects models and differences in proportions to compare rates of resource referrals by implementation strategy, and intention-to-treat analysis to compare odds of engagement with new resources among families enrolled in the Usual Care vs. WE CARE phases. DISCUSSION: Findings from this trial may inform decisions about broader dissemination of SDOH screening systems into a diverse spectrum of pediatric practices across the US and potentially minimize the impact of adverse SDOH on children and families.
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Padres , Determinantes Sociales de la Salud , Niño , Humanos , Encuestas y Cuestionarios , Atención Primaria de Salud , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
OBJECTIVES: To describe adherence to the American Academy of Pediatrics' (AAP) 2017 clinical practice guidelines for follow-up after high blood pressure (BP) screening by pediatric and family medicine providers in a Massachusetts health care system and to assess differences in receipt of follow-up according to child- and clinic-level factors. METHODS: Electronic health record data were analyzed for children aged 3 to 17years who had an outpatient primary care visit during 2018 with a high BP screening (according to AAP guidelines). We classified AAP guideline adherent follow-up as BP follow-up within 6months after an elevated finding (+2-week buffer) and within 2weeks after a hypertensive finding (+2-week buffer). Differences in receipt of guideline adherent follow-up by child- and clinic-level factors were assessed via multilevel mixed effects logistic regression models. RESULTS: The median age of the 4563 included children was 12years and 43% were female. Overall, guideline adherent follow-up was received by 17.7% of children within the recommended time interval; 27.4% for those whose index BP was elevated and 5.4% for those whose index BP was hypertensive. Modeling revealed older children and those belonging to clinics with more providers, smaller patient panels, and smaller proportion of Medicaid patients were more likely to receive adherent follow-up. CONCLUSIONS: Few children received guideline adherent BP follow-up and most differences in adherence were related to clinic resources. System-level interventions are needed to improve BP follow-up.
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Adhesión a Directriz , Hipertensión , Niño , Humanos , Femenino , Estados Unidos , Adolescente , Masculino , Estudios de Seguimiento , Hipertensión/terapia , Hipertensión/diagnóstico , Massachusetts , Atención a la SaludRESUMEN
BACKGROUND: Parents of children with special health care needs (CSHCN) are at risk of poorer health outcomes. Material hardships also pose significant health risks to parents. Little is known about how protective factors may mitigate these risks and if effects are similar between mothers and fathers. METHODS: This was a cross-sectional survey study conducted using the US 2018/2019 National Survey of Children's Health, including parents of children 0 to 17 with income <200% of the federal poverty level. Separately, for parents of children with and without special health care needs (N-CSHCN), weighted logistic regression measured associations between material hardship, protective factors (family resilience, neighborhood cohesion, and receipt of family-centered care), and 2 outcomes: mental and physical health of mothers and fathers. Interactions were assessed between special health care needs status, material hardship, and protective factors. RESULTS: Sample consisted of parents of 16,777 children; 4440 were parents of CSHCN. Most outcomes showed similar associations for both mothers and fathers of CSHCN and N-CSHCN: material hardship was associated with poorer health outcomes, and family resilience and neighborhood cohesion associated with better parental health outcomes. Family-centered care was associated with better health of mothers but not fathers. Interaction testing showed that the protective effects of family resilience were lower among fathers of CSHCN experiencing material hardship. CONCLUSIONS: Family resilience and neighborhood cohesion are associated with better health outcomes for all parents, though these effects may vary by experience of special health care needs, parent gender, and material hardship.
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Niños con Discapacidad , Resiliencia Psicológica , Niño , Femenino , Humanos , Salud Infantil , Estudios Transversales , Salud de la Familia , Factores Protectores , Accesibilidad a los Servicios de Salud , Necesidades y Demandas de Servicios de SaludRESUMEN
This Viewpoint discusses 5 principal challenges and opportunities for the sustainable implementation of social determinants of health interventions in emergency department settings.
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Servicio de Urgencia en Hospital , Determinantes Sociales de la Salud , Niño , HumanosRESUMEN
This Viewpoint discusses recently established quality measures designed to screen patients for health-related social needs and how they may not only come up short, but impede progress in health equity.
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OBJECTIVE: To describe the prevalence of blood pressure (BP) screening according to the 2017 American Academy of Pediatrics (AAP) guidelines and differences according to social vulnerability indicators. STUDY DESIGN: We extracted electronic health record data from January 1, 2018, through December 31, 2018, from the largest healthcare system in Central Massachusetts. Outpatient visits for children aged 3-17 years without a prior hypertension diagnosis were included. Adherence was defined by the American Academy of Pediatrics guideline (≥1 BP screening for children with a body mass index [BMI] of <95th percentile) and at every encounter for children with a BMI of ≥95th percentile). Independent variables included social vulnerability indicators at the patient level (insurance type, language, Child Opportunity Index, race/ethnicity) and clinic level (location, Medicaid population). Covariates included child's age, sex, and BMI status, and clinic specialty, patient panel size, and number of healthcare providers. We used direct estimation to calculate prevalence estimates and multivariable mixed effects logistic regression to determine the odds of receiving guideline-adherent BP screening. RESULTS: Our sample comprised 19â695 children (median age, 11 years; 48% female) from 7 pediatric and 20 family medicine clinics. The prevalence of guideline-adherent BP screening was 89%. In our adjusted model, children with a BMI of ≥95th percentile, with public insurance, and who were patients at clinics with larger Medicaid populations and larger patient panels had a lower odds of receiving guideline-adherent BP screening. CONCLUSIONS: Despite overall high adherence to BP screening guidelines, patient- and clinic-level disparities were identified.
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Registros Electrónicos de Salud , Hipertensión , Niño , Humanos , Femenino , Masculino , Presión Sanguínea , Hipertensión/diagnóstico , Hipertensión/epidemiología , Massachusetts/epidemiología , Atención a la Salud , Disparidades en Atención de SaludRESUMEN
BACKGROUND: Children with sickle cell anemia (SCA) have substantial medical needs and more unmet basic needs than children with other medical conditions. Despite a recent focus on social determinants of health (SDoH), there remains an incomplete understanding of the processes linking SDoH and disease management, particularly for youth with SCA. This study elucidated these processes and identified ways to mitigate deleterious effects of adverse SDoH on SCA management. METHODS: Parents/primary caregivers (N = 27) of children with SCA (≤12 years old) participated in semi-structured interviews regarding SCA management and SDoH and completed quantitative measures of basic needs. Qualitative data were systematically coded and analyzed using applied thematic analysis. Quantitative data were presented descriptively. RESULTS: Three qualitative themes were identified. First, SCA management is bidirectionally linked with the social environment, whereby challenges of SCA management can hinder basic needs from being met, and unmet basic needs and financial hardship hinder SCA management. Second, due to limited resources, parents/caregivers are faced with difficult choices between prioritizing basic needs versus SCA management. Third, addressing material, emotional, and informational needs may improve SCA management. Quantitatively, 73% of families endorsed ≥1 basic need, including food insecurity (42%), housing instability (62%), and/or energy insecurity 19% (vs. 20%). CONCLUSION: Despite documented associations, there remains a poor understanding of the processes linking SDoH and health. Findings underscore how day-to-day conditions undermine the management of SCA treatments, symptoms, and complications, limiting treatment effectiveness. Understanding these processes may inform family-centered, health equity interventions and policies to improve living conditions, disease management, and health outcomes.
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Anemia de Células Falciformes , Determinantes Sociales de la Salud , Adolescente , Niño , Humanos , Padres , Investigación Cualitativa , Anemia de Células Falciformes/terapia , Encuestas y CuestionariosRESUMEN
OBJECTIVES: To assess the implementation and effectiveness of the augmented WE CARE social care system on low-income children's health care utilization and child maltreatment outcomes. METHODS: We conducted a type 1 hybrid effectiveness-implementation cluster randomized controlled trial at 6 community health centers. Full-term infants were followed from birth to age 3. The 3 experimental clinics implemented the augmented WE CARE system at well-child visits, consisting of a self-report screening instrument for 7 basic needs; an electronic health record-generated resource information referral system; and access to a peer patient navigator. Families at control community health centers received usual care; 1 control site was contaminated and removed from primary analysis. We analyzed results using generalized mixed-effects models. RESULTS: Overall, 878 children were followed until age 3. Implementation of WE CARE was poor with only 28.9% of visits having a WE CARE screener documented. WE CARE families received significantly more resource referrals than control families (43.1% vs 1.9%, adjusted odds ratio 4.6; 95% confidence interval, 2.0-5.6); 20% were referred to the patient navigator. WE CARE children had significantly higher immunization adherence ratios. Although there were no statistically significant differences with well-child visits, WE CARE children had higher rates of emergency department visits than control children. By age 3, WE CARE children had significantly higher hospitalization rates (14.1% vs 10.4%, adjusted odds ratio 1.3, 95% confidence interval: 1.03-1.7). There were no statistically significant differences with maltreatment outcomes. CONCLUSIONS: We found poor implementation and mixed benefits for the augmented WE CARE system on immunization, health care utilization, and maltreatment outcomes in early childhood.
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Maltrato a los Niños , Aceptación de la Atención de Salud , Lactante , Niño , Humanos , Preescolar , Salud Infantil , Apoyo Social , Maltrato a los Niños/prevención & control , Atención Primaria de SaludRESUMEN
This review summarizes the current pediatric literature related to social determinants of health, including strengths and weaknesses of screening practices and intervention strategies, common concerns and potential unintended consequences, opportunities for further research, and provides evidence-informed practical strategies for clinicians.
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Determinantes Sociales de la Salud , Niño , HumanosAsunto(s)
Cuidadores , Pacientes Internos , Niño , Humanos , Población Urbana , Padres , Apoyo Social , HospitalesRESUMEN
This Viewpoint describes how pediatric health care systems can use health-related social needs screening implementation as an opportunity to reimagine more healing-centered systems.
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Programas de Gobierno , Tamizaje Masivo , Humanos , Evaluación de NecesidadesRESUMEN
BACKGROUND: Asthma is one of the most prevalent chronic diseases of childhood and disproportionately affects children with lower socioeconomic status. Controller medications such as inhaled corticosteroids significantly reduce asthma exacerbations and improve symptoms. However, a large proportion of children still have poor asthma control, in part owing to suboptimal adherence. Financial barriers contribute to hindering adherence, as do behavioral factors related to low income. For example, unmet social needs for food, lodging, and childcare may create stress and worry in parents, negatively influencing medication adherence. These needs are also cognitively taxing and force families to focus on immediate needs, leading to scarcity and heightening future discounting; thus, there is the tendency to attribute greater value to the present than to the future in making decisions. OBJECTIVE: In this project, we will investigate the relationship between unmet social needs, scarcity, and future discounting as well as their predictive power over time on medication adherence in children with asthma. METHODS: This 12-month prospective observational cohort study will recruit 200 families of children aged 2 to 17 years at the Asthma Clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary care pediatric hospital in Montreal, Canada. The primary outcome will be adherence to controller medication, measured using the proportion of prescribed days covered during follow-up. Exploratory outcomes will include health care use. The main independent variables will be unmet social needs, scarcity, and future discounting, measured using validated instruments. These variables will be measured at recruitment as well as at 6- and 12-month follow-ups. Covariates will include sociodemographics, disease and treatment characteristics, and parental stress. Primary analysis will compare adherence to controller medication, measured using the proportion of prescribed days covered, between families with versus those without unmet social needs during the study period using multivariate linear regression. RESULTS: The research activities of this study began in December 2021. Participant enrollment and data collection began in August 2022 and are expected to continue until September 2024. CONCLUSIONS: This project will allow the documentation of the impact of unmet social needs, scarcity, and future discounting on adherence in children with asthma using robust metrics of adherence and validated measures of scarcity and future discounting. If the relationship between unmet social needs, behavioral factors, and adherence is supported by our findings, this will suggest the potential for novel targets for integrated social care interventions to improve adherence to controller medication and reduce risk across the life course for vulnerable children with asthma. TRIAL REGISTRATION: ClinicalTrials.gov NCT05278000; https://clinicaltrials.gov/ct2/show/NCT05278000. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37318.