Racial Disparities in Technology Use in Children With Type 1 Diabetes: A Qualitative Content Analysis of Parents' Perspectives.

PURPOSE: The purpose of the study was to describe differences in non-Hispanic Black (NHB) and non-Hispanic White (NHW) parents' perceptions of factors that influence the use of diabetes technology. METHODS: Focus groups were conducted with parents of NHB and NHW children at a pediatric diabetes center in the Northeast United States. Kilbourne's health disparities framework informed the focus group guide and a priori coding for directed content analysis. Further analysis allowed subcategories to emerge inductively. RESULTS: Twenty-one parents participated. Five subcategories emerged, describing differences in NHB and NHW parent decisions regarding diabetes technology: (1) child's choice, (2) shame versus pride, (3) pros and cons of technology, (4) time frame, and (5) blood glucose indications of readiness. NHB parents feared technology malfunction, worried that visible devices could worsen experienced stigma of diabetes diagnosis, and described the diabetes team as gatekeepers, who changed eligibility criteria for diabetes technology use for their research purposes. In contrast, NHW parents reported diabetes team expectation of diabetes technology use and did not report provider-related barriers. CONCLUSION: This study adds to existing literature advancing our understanding of the patient and provider mechanisms underlying racial disparities in diabetes technology use. This understanding may guide development of interventions focused on patients, providers, and structural factors to improve equity in use of diabetes technology by youth with type 1 diabetes.

Perspectives of Pediatric Community Health Workers: Roles, Successes, and Challenges.

This multicenter qualitative study described the roles of 10 pediatric community health workers (CHWs) in their own words through exploration of the role features, successes, and challenges in pediatric health care settings across three urban U.S. cities (Philadelphia, New York City, and Cincinnati). Individual, semi-structured telephone interviews were conducted. Interviews described prominent features of the pediatric CHW role, which included taking a family-centered approach to goal setting and determining support needed, ensuring family goals stayed at the center of the work, and acting as a trusted figure for families to talk openly with. CHWs described their role as rewarding, believing in the work, and feeling a sense of fulfillment, and felt successful when families had positive outcomes, including when barriers were eliminated, resources were obtained, or independence was demonstrated by families. Challenges CHWs faced in their roles included establishing trust with families, managing the ever-changing family circumstances many families experience due to socioeconomic barriers, and managing limitations of protocol and restrictions within their roles. This study demonstrated numerous considerations for CHW practice in pediatric health care settings, in addition to considerations for pediatric-specific CHW program development and management. The primary policy implication of this study included a basis for increased funding for CHW programs in pediatric health care settings. This study also demonstrated a need for further research on the change CHWs effect within child and family systems outside of health care, such as schools and child welfare agencies.

Underrepresented Voices: Impacts of Social Determinants of Health on Type 1 Diabetes Family Management in Single-Parent, Black Families.

OBJECTIVES: Social determinants of health (SDOH) impact families' ability to manage chronic illnesses such as type 1 diabetes (T1D). Black, single parents have unique SDOH-related resource needs and concerns when caring for a child with a chronic illness, yet their voices are underrepresented in the pediatric T1D literature. The aim of this qualitative study was to identify and explore the SDOH that influence T1D management in Black, single-parent families. METHODS: In this 2-phase qualitative study we used content analysis to explore themes derived from 3 nominal group technique sessions and semistructured interviews, with 20 self-identified Black, single parents of a child with T1D. RESULTS: Parents encountered various SDOH-related issues that negatively influenced management of their children's T1D. Six major themes emerged from the parent-generated list of SDOH-related barriers: 1) lack of parent and child emotional and physical support systems, 2) maintaining parent and child's physical and mental health, 3) pain management with medication administration, 4) clinical team empathy, 5) provider communication, and 6) economic burden of food costs. CONCLUSIONS: These exploratory findings contribute to the knowledge base required to guide development of culturally relevant, individual- and population-level interventions for racially and compositionally minority families, to increase health equity and address racial health disparities in T1D. Routine assessment of family social support context and resources, better integration of community-level social services into clinical health encounters and clinician bias and communication training are advised starting points to address the specific needs of racial and ethnic minority families experiencing the greatest social and clinical challenges.

COVID-19 Vaccine Acceptance and Access Among Black and Latinx Communities.

Importance: Black and Latinx communities have faced disproportionate harm from the COVID-19 pandemic. Increasing COVID-19 vaccine acceptance and access has the potential to mitigate mortality and morbidity from COVID-19 for all communities, including those most impacted by the pandemic. Objective: To investigate and understand factors associated with facilitating and obstructing COVID-19 vaccine access and acceptance among Black and Latinx communities. Design, Setting, and Participants: This community-partnered qualitative study conducted semistructured, in-depth focus groups with Black and Latinx participants from March 17 to March 29, 2021, using a secure video conferencing platform. Participants were recruited through emails from local community-based organizations, federally qualified health centers, social service agencies, the New Haven, Connecticut, Health Department, and in-person distribution of study information from community health workers. A total of 8 focus groups were conducted, including 4 in Spanish and 4 in English, with 72 participants from a diverse range of community roles, including teachers, custodial service workers, and health care employees, in New Haven, Connecticut. Data were analyzed from March 17 to July 30, 2021. Main Outcomes and Measures: Interviews were audio-recorded, transcribed, translated, and analyzed using an inductive content analysis approach. Themes and subthemes were identified on the acceptability and accessibility of the COVID-19 vaccine among participants who identified as Black and/or Latinx. Results: Among 72 participants, 36 (50%) identified as Black, 28 (39%) as Latinx, and 8 (11%) as Black and Latinx and 56 (78%) identified as women and 16 (22%) identified as men. Participants described 3 major themes that may represent facilitators and barriers to COVID-19 vaccinations: pervasive mistreatment of Black and Latinx communities and associated distrust; informing trust via trusted messengers and messages, choice, social support, and diversity; and addressing structural barriers to vaccination access. Conclusions and Relevance: The findings of this qualitative study may impact what health care systems, public health officials, policy makers, health care practitioners, and community leaders can do to facilitate equitable uptake of the COVID-19 vaccine. Community-informed insights are imperative to facilitating COVID-19 vaccine access and acceptance among communities hardest hit by the pandemic. Preventing the further widening of inequities and addressing structural barriers to vaccination access are vital to protecting all communities, especially Black and Latinx individuals who have experienced disproportionate death and loss from COVID-19.

Influence of social determinants of health barriers to family management of type 1 diabetes in Black single parent families: A mixed methods study.

OBJECTIVE: US disparities in pediatric type 1 diabetes treatment and outcomes are increasing disproportionately among Black youth and compounded for youth from single parent homes. Despite worsened outcomes, Black youth from single parent homes and their caregivers are underrepresented in pediatric type 1 diabetes research. The purpose of this study was to understand the social determinants of health (SDOH) barriers that may contribute to health disparities and family management in Black youth with type 1 diabetes from single parent homes. RESEARCH DESIGN AND METHODS: A three-phase mixed methods study with self-identified Black single parents of youth with type 1 diabetes from an urban US pediatric diabetes center was conducted. Focus groups and interviews informed development of a parent-generated survey of SDOH barriers to diabetes management. Survey results are presented. RESULTS: A resulting 71 item parent-generated survey was administered to 105 parents. Among all items, most problematic SDOH barriers included lack of social support, managing parent/child diabetes-related stress, difficulties accessing diabetes supplies, pain management, cost of food and diabetes camp, need to take time off from work, lack of skilled school staff, school absences and unsafe neighborhoods. Structural racism related to child welfare reporting, and police targeting were also notable concerns. CONCLUSIONS: There is a critical need for clinical, community, and policy-related research and interventions, designed to reduce type 1 diabetes racial health disparities by addressing the impacts of SDOH as drivers of family management outcomes among Black youth from single parent families.

Social Determinants of Health, Goals and Outcomes in High-Risk Children With Type 1 Diabetes.

OBJECTIVES: Despite advances in technology and type 1 diabetes (T1D) care, children from low-income families continue to have suboptimal outcomes and increased health-care utilization. In this study, we describe social determinants of health (SDOH) in high-risk children with T1D, as well as their SDOH-related priority goals, and assess the correlation between SDOH, glycemic control and health-care utilization. METHODS: Caregivers of children aged 4 to 18 years with a diagnosis of T1D of >1 year, poor glycemic control (glycated hemoglobin [A1C] ≥9.5%) or high health-care utilization (≥2 diabetes-related hospitalizations, emergency department attendances or missed outpatient appointments in the previous year) were included. Primary caregiver health-related quality of life (HRQOL), self-efficacy (Maternal Self-Efficacy in Diabetes [MSED] scale) and SDOH were assessed. Goals were identified after assessment by a community health worker. RESULTS: Fifty-three families were included, most (n=48, 91%) of whom had government insurance. Children had a median age of 13.4 (interquartile range [IQR], 12 to 15.3) years and a median A1C of 11.1% (IQR, 10% to 13%). Almost half of the families (n=24, 45%) reported at least 1 adverse SDOH. One or more adverse SDOH was associated with significantly lower total HRQOL scores (56.6 [IQR, 38.5 to 70.7] vs 77.8 [IQR, 60.8 to 92.4], p=0.004), but not associated with A1C (p=0.3), emergency department visits (p=0.9) or MSED (p=0.5). CONCLUSIONS: Screening for adverse SDOH and addressing these barriers to glycemic control is not part of routine T1D care. In children with poorly controlled T1D and high health-care utilization, we have demonstrated a high prevalence of adverse SDOH, which may represent a modifiable factor to improve outcomes in this patient population.

Vaccipack, A Mobile App to Promote Human Papillomavirus Vaccine Uptake Among Adolescents Aged 11 to 14 Years: Development and Usability Study.

BACKGROUND: More than 90% of human papillomavirus (HPV)-related cancers could be prevented by widespread uptake of the HPV vaccine, yet vaccine use in the United States falls short of public health goals. OBJECTIVE: The purpose of this study was to describe the development, acceptability, and intention to use the mobile app Vaccipack, which was designed to promote uptake and completion of the adolescent HPV vaccine series. METHODS: Development of the mobile health (mHealth) content was based on the integrated behavioral model (IBM). The technology acceptance model (TAM) was used to guide the app usability evaluation. App design utilized an iterative process involving providers and potential users who were parents and adolescents. App features include a vaccine-tracking function, a discussion forum, and stories with embedded messages to promote intention to vaccinate. Parents and adolescents completed surveys before and after introducing the app in a pediatric primary care setting with low HPV vaccination rates. RESULTS: Surveys were completed by 54 participants (20 adolescents aged 11 to 14 years and 34 parents). Notably, 75% (15/20) of adolescents and 88% (30/34) of parents intended to use the app in the next 2 weeks. Acceptability of the app was high among both groups: 88% (30/34) of parents and 75% (15/20) of adolescents indicated that Vaccipack was easy to use, and 82% (28/34) of parents and 85% (17/20) of adolescents perceived the app to be beneficial. Higher levels of app acceptability were found among parents with strong intentions to use the app (P=.09; 95% CI -2.15 to 0.15). CONCLUSIONS: mHealth technology, such as Vaccipack, may be an acceptable and nimble platform for providing information to parents and adolescents and advancing the uptake of important vaccines.

Systematic review of sociodemographic representation and cultural responsiveness in psychosocial and behavioral interventions with adolescents with type 1 diabetes.

BACKGROUND: The increasing incidence of type 1 diabetes (T1D) in youth aged less than 20 years in the USA is a mounting public health concern. Specific sociodemographic characteristics-racial/ethnic minority, low socioeconomic status (SES), single-parent home and underinsured-have been associated with increased risk for poor glycemic control and poor self-management in adolescents with T1D. METHODS: Sample demographic and cultural responsiveness methods in psychosocial and behavioral interventions focused on improving self-management and glycemic control in adolescents with T1D were systematically evaluated, to identify if studies were targeting these high-risk groups. Keyword searches of PsychInfo, PubMed and CINAHL identified 259 studies published between 2006 and 2016, of adolescents (13-18 years old) with T1D; 28 studies met inclusion criteria. RESULTS: Samples focused predominantly on White adolescents with fair glycemic control, from middle-high income, two-parent households with private insurance. The majority of studies scored poorly in cultural responsiveness and moderately in culturally responsive reporting. Studies lacked descriptions of culturally inclusive recruitment and sampling methods, and use of culturally responsive assessments for diverse groups. The majority of studies recruited and enrolled homogeneous adolescent samples from the lowest risk groups. CONCLUSION: T1D intervention researchers must increase targeted recruitment and sampling methods to include more high-risk pediatric T1D groups, expand sociodemographic reporting, and increase the use of culturally responsive recruitment and sampling methods, such as those used in community-based participatory research. Such efforts have the potential to reduce T1D disparities by making interventions more relevant to the unique needs, goals and priorities of highest risk groups.

An Integrative Review of Social Determinants of Health Assessment and Screening Tools Used in Pediatrics.

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.