Cash Transfers and After-School Programs: A Randomized Controlled Trial for Young Men at Risk of Violence Exposure in Wilmington, Delaware.

We conducted a randomized controlled trial to determine whether an after-school program paired with a cash transfer (a conditional cash transfer) or a cash transfer alone (an unconditional cash transfer) can help improve health and economic outcomes for young men between the ages of 14 and 17 whose parents have low incomes and who live in neighborhoods with high crime rates. We find that receiving the cash transfer alone was associated with an increase in healthy behaviors (one of our primary outcome composite measures) and that the cash transfer paired with after-school programming was associated with an improvement in the financial health of participants (one of our secondary outcome composite measures). We find no differences in spending on alcohol, marijuana, cigarettes, or other drugs between either the treatment group and the control group. Neither the cash transfer alone nor the programming plus cash transfer had statistically significant effects on our other primary composite measures (physical and mental health or school attendance and disciplinary actions), or our other secondary composite measures (criminal justice engagement or social supports) but in most cases, confidence intervals were too large to rule out meaningful effects. Results suggest that cash transfers hold promise to improve the health of youth without any indication of any adverse effects.

Alternative Payment Models and Working with Payers-Key Considerations for Advancing Population Health Goals and Achieving Child Health Equity.

This article summarizes approaches to achieving value-based care in Pediatrics, providing a framework for understanding the continuum of models from fee-for-service to advanced alternative payment models. We present key examples of how alternative payment models have been developed and applied at the federal level within Medicare through the work of the Centers for Medicare and Medicaid Services (CMS) and the Center for Medicaid and Medicaid Innovation (CMMI). We further describe key lessons learned and opportunities to adapt value-based payment models to promote whole child health and equity. Finally, we summarize policy considerations and challenges in achieving accountability and aligning financial incentives for children's health within a complex payer landscape.

Addressing population health inequities: investing in the social determinants of health for children and families to advance child health equity.

PURPOSE OF REVIEW: This review provides a critical assessment of recent pediatric population health research with a specific focus on child health equity. The review addresses: the role of the healthcare sector in addressing fundamental social drivers of health, challenges within healthcare organizations in addressing health-related social needs and the social determinants of health, and the rationale for incorporating race and racism in pediatric population health research and practice. RECENT FINDINGS: The coronavirus disease 2019 pandemic brought greater attention to the disparities and inequities in American health and healthcare. In response to these stark inequities, many health systems are adopting efforts and initiatives to address social needs, social determinants of health, racism, and health equity. However, empirical evaluation detailing the effectiveness of these interventions and initiatives is limited. SUMMARY: While attention to identifying social needs among pediatric populations is increasing, there is limited evidence regarding the effectiveness of these interventions in producing sustained reductions in health disparities. To advance child health equity, researchers should move beyond individual behavior modification and directly examine fundamental drivers of health inequities. These drivers include government and health policies as well as societal forces such as systemic racism.

Effects of a Curriculum Addressing Racism on Pediatric Residents' Racial Biases and Empathy.

Background: Racism is a longstanding driver of health inequities. Although medical education is a potential solution to address racism in health care, best practices remain unknown. Objective: We sought to evaluate the impact of participation in a curriculum addressing racism on pediatric residents' racial biases and empathy. Methods: A pre-post survey study was conducted in 2 urban, university-based, midsized pediatric residency programs between July 2019 and June 2020. The curriculum sessions included Self-Reflection on Implicit Bias, Historical Trauma, and Structural Racism. All sessions were paired with empathy and perspective-taking exercises and were conducted in small groups to facilitate reflective discussion. Wilcoxon signed rank tests were used to assess changes in racial bias and empathy. Linear regression was used to assess the effect of resident characteristics on racial bias and empathy. Results: Ninety of 111 residents receiving the curriculum completed pre-surveys (81.1%), and among those, 65 completed post-surveys (72.2%). Among participants with baseline pro-White bias, there was a statistically significant shift (0.46 to 0.36, P=.02) toward no preference. Among participants with a baseline pro-Black bias, there was a statistically significant shift (-0.38 to -0.21, P=.02), toward no preference. Among participants with baseline pro-White explicit bias, there was a statistically significant shift (0.54 to 0.30, P<.001) toward no preference. Among all residents, there was a modest but statistically significant decrease in mean empathy (22.95 to 22.42, P=.03). Conclusions: Participation in a longitudinal discussion-based curriculum addressing racism modestly reduced pediatric residents' racial preferences with minimal effects on empathy scales.

The development and implementation of a new hospital performance measure to assess hospital contributions to community health and equity.

OBJECTIVE: To develop and implement a measure of how US hospitals contribute to community health with a focus on equity. DATA SOURCES: Primary data from public comments and hospital surveys and secondary data from the IBM Watson Top 100 Hospitals program collected in the United States in 2020 and 2021. STUDY DESIGN: A thematic analysis of public comments on the proposed measure was conducted using an iterative grounded approach for theme identification. A cross-sectional survey of 207 hospitals was conducted to assess self-attestation to 28 community health best practice standards in the revised measure. An analysis of hospital rankings before and after inclusion of the new measure was performed. DATA COLLECTION/EXTRACTION METHODS: Public comment on the proposed measure was collected via an online survey, email, and virtual meetings in 2020. The survey of hospitals was conducted online by IBM in 2021. The analysis of hospital ranking compared the 2020 and 2021 IBM Watson Top 100 Hospitals program results. PRINCIPAL FINDINGS: More than 650 discrete comments from 83 stakeholders were received and analyzed during measure development. Key themes identified in thematic analysis included equity, fairness, and community priorities. Hospitals that responded to a cross-sectional survey reported meeting on average 76% of applicable best practice standards. Least met standards included providing emergent buprenorphine treatment for opioid use disorder (53%), supporting an evidence-based home visiting program (53%), and establishing a returning citizens employment program (27%). Thirty-seven hospitals shifted position in the 100 Top Hospital rankings after the inclusion of the new measure. CONCLUSIONS: There is broad interest in measuring hospital contributions to community health with a focus on equity. Many highly ranked hospitals report meeting best practice standards, but significant gaps remain. Improving measurement to incentivize greater hospital contributions to community health and equity is an important priority.

A systems framework depicting how complex neighborhood dynamics and contextual factors could impact the effectiveness of an alcohol outlet zoning policy.

An updated zoning policy eliminating all alcohol outlets (liquor stores) in residential districts was implemented to reduce high rates of violent crime in Baltimore City. Diverse stakeholders were engaged in group model building (GMB) activities to develop causal loop diagrams (CLDs) that elucidate the impact of the new zoning policy on crime, and more broadly, the potentially unintended social and environmental consequences of the policy. Three distinct groups, community advocates, city officials/academics, and community residents, participated in three separate GMB sessions. Three CLDs, one from each stakeholder group, were created to depict the possible outcomes of the zoning policy. Our findings offer insight into potential unintended consequences of removing liquor stores from residential areas that may undermine the policy. Community members described the need for additional supports related to mental health and substance use, opportunities for investment in the community, access to other goods and services, and community-police relations to ensure the policy achieved its intended goal of reducing violent crime. Our findings highlight the importance of timely engagement of local stakeholders to understand how complex neighborhood dynamics and contextual factors could impact the effectiveness of a zoning policy change.

Racial/Ethnic Disparities in Parent Activation: Implications for Developing Interventions Addressing Early Childhood Obesity.

OBJECTIVE: Examine racial/ethnic differences in parent activation and associations with child obesity risk behaviors in low-income families. METHODS: Cross-sectional survey study of 300 low-income Black, Latinx, and White parents of patients aged 2 to 5 years receiving primary care within 2 health care systems (Systems 1 & 2). In-person and phone surveys were conducted. Parent activation, defined as parents' knowledge, confidence, and willingness to act concerning their child's health, was measured using the standardized 13-item Parent Patient Activation Measure (P-PAM). Differences in parent activation by race/ethnicity were assessed using analysis of variance. Multivariate regression analyses were used to test associations between parent activation and child obesity risk behaviors. RESULTS: In pooled unadjusted analyses, Latinx parents had significantly lower activation compared to Black parents (P = .023), but these differences were no longer statistically significant after adjusting for other sociodemographic characteristics (P = .06). Higher activation was associated with slightly greater odds of consuming ≥ 5 daily servings of fruits and vegetables for System 2 only (odds ratio: 1.04, 95% confidence interval: 1.01, 1.07). Associations between parental activation and child screen time or physical activity were not significant. CONCLUSIONS: Findings highlight potential measurement limitations of the P-PAM including the inability of the measure to capture barriers to health system navigation and cultural and linguistic considerations. Further attention to the nuanced interplay between parental activation and contextual and sociodemographic risk factors (eg, food availability, immigrant status, economic opportunity, language proficiency) should be considered in the development of early childhood obesity interventions in primary care settings.

Police Exposures and the Health and Well-being of Black Youth in the US: A Systematic Review.

Importance: Black youth in the US experience disproportionate contact with police even when accounting for criminal or delinquent behavior, which some experts say is fueled by racism and discrimination. While the literature supports the link between racism and adverse health outcomes, less is known about the impact of policing on the well-being of Black youth. Objective: To systematically review the literature describing the association between police exposure and health outcomes for Black youth 26 years and younger. Evidence Review: A search of PubMed, Embase, Criminal Justice Abstracts, PsycInfo, and Web of Science was conducted. Eligible studies included original peer-reviewed research published from 1980 to December 2020, with a participant population of Black youth, a focus on police exposure, and health as the outcome. Additional articles were identified by hand-searching reference lists of included studies. Data extraction was performed, followed by critical appraisal of all included studies using a convergent segregated approach in which quantitative and qualitative studies were synthesized separately followed by an overarching synthesis across methods. Findings: A total of 16 quantitative studies including 19 493 participants were included in the review and demonstrated an association between police exposure and adverse mental health, sexual risk behaviors, and substance use. A total of 13 qualitative studies including 461 participants were included in the review, which corroborated and contextualized the quantitative evidence and provided additional health outcomes, such as fear for life or hopelessness. Conclusions and Relevance: Evidence shows that police exposures are associated with adverse health outcomes for Black youth. Clinicians, scientists, public health practitioners, and policy makers can partner with local governments to enact reforms that mitigate the health impact of policing on youth.

"It Makes Me a Better Person and Doctor": A Qualitative Study of Residents' Perceptions of a Curriculum Addressing Racism.

OBJECTIVE: Explore how pediatric residents perceive the impact of a curriculum addressing racism on their knowledge, motivation, skills and behaviors, and investigate the contextual factors that promote or impede the curriculum's effectiveness. METHODS: Open-ended, semistructured interviews were conducted at 2 academic medical centers between August 2019 and 2020 among pediatric residents who participated in the curriculum. Interviews were recorded, transcribed, and analyzed by using inductive content analysis. RESULTS: Pediatric residents (n = 16) were predominantly white (66.7%), female (86.7%) interns (60%) from the Midwest (40%). Six major themes emerged describing the perceived impact of the curriculum on: knowledge - (1) Understanding of race and racism as structural forces in a historical context; motivation - (2) Owning the issue of racism, (3) Having the curriculum makes a statement; skills - (4) Critical self-reflection, (5) Perceived development of skills to mitigate biases; and action-planning - (6) Turning insight into strategies to combat racism and improve patient care. Two additional themes emerged describing contextual factors that promoted or impeded the curriculum such as the content of the curriculum itself, the racial demographics of the participants, the implementation infrastructure and environmental factors such as the culture of the training program. CONCLUSIONS: Medical education addressing racism can facilitate the perceived acquisition of foundational knowledge regarding race and racism; motivation and skill-building to combat racism; and action planning aimed at improving patient care. Contextual factors should be considered when developing and implementing such curricula to not only promote racial equity but avoid unintended harms.

Timing of Supplemental Nutrition Assistance Program Benefits and Families' Home Food Environments.

BACKGROUND AND OBJECTIVES: Supplemental Nutrition Assistance Program (SNAP) benefits are designed to buffer families from food insecurity, but studies suggest that most benefits are used by midmonth. In this study, we examined whether the home food environment varies across the SNAP benefits cycle among participating families . METHODS: Participants in this mixed-methods study were 30 SNAP participants who were primary caregivers of a child ages 4-10 years. The home food environment was measured 1 week before SNAP benefit replenishment and again within 1 week after replenishment by using the Home Food Inventory. Household food insecurity was assessed by using the US Department of Agriculture Household Food Security Survey. Wilcoxon rank tests were used to evaluate changes in median Home Food Inventory subscales and food insecurity pre- to post-replenishment. Qualitative interviews with participating caregivers were conducted to explore contextual factors influencing the home food environment across the benefits cycle. RESULTS: Participants had significantly fewer types of vegetables (median: 7.0 vs 8.5, median difference 1.73, 95% confidence interval: 0.5-2.5, P = .03) and higher food insecurity pre- versus post-replenishment (median: 4.0 vs 2.0, median difference 1, 95% confidence interval: 0.1-1.5, P = .03). Caregivers described employing a variety of intentional strategies to reduce cyclic variation in food availability. CONCLUSIONS: Findings suggest that there is relatively limited cyclic variation in the home food environment among families participating in SNAP. This may be explained by a number of assistance programs and behavioral strategies caregivers used to make food last and buffer against scarcity. Future research should evaluate the relationship between the degree of home food environment changes and child health outcomes.

Parents lose less weight than nonparents in an intensive lifestyle intervention.

OBJECTIVE: Understand whether parents lose less weight than nonparents in behavioural weight interventions. METHODS: The Look AHEAD (Action for Health in Diabetes) trial randomized adults with Type 2 diabetes and overweight to an intensive lifestyle intervention (ILI) or control (diabetes support and education [DSE]). Participants who reported living with a child under age 18 were designated as 'parents' for this analysis. Intention to treat analysis was performed of the effect of the ILI on change in weight at 1 year by parental status. Adherence to attending intervention visits was compared between parents and nonparents. Subgroup analyses were done based on previous subgroup findings in the Look AHEAD study. RESULTS: Among 4,547 participants, 15% were parents. Parents were younger and more likely to have self-identified as African American or Hispanic/Latino. Comparing ILI with DSE, parents lost less weight than nonparents (-7.1% vs. -8.3%, p = 0.021). African American female parents lost 4% body weight compared with 7% in African American female nonparents (p = 0.01). CONCLUSIONS: In a randomized trial, parents lost less weight than nonparents, and this difference was largest for African American women. These findings suggest parents face unique challenges achieving weight loss; more research is needed to understand and optimize interventions for parents.

Using Land Policy to Improve Population Health.

We examine whether zoning can increase health equity and population health by assessing a new zoning ordinance in the City of Baltimore that forced 76 liquor stores in residential areas to relocate, close, or convert to an approved use. To do so, we undertake a baseline assessment of neighborhoods with affected liquor stores, and predict the potential impact of the zoning change by estimating the impact of previous closures and openings of liquor stores on neighborhood crime in Baltimore using a spatial Poisson random trend fixed effects model. We find that affected stores are concentrated in high poverty, majority black neighborhoods with high vacancy rates, and that liquor store closings are associated with a statistically significant reduction in violent crime on the block group in question with no negative spillover affects onto the nearby block groups.

Neighborhood Environment Characteristics and Control of Hypertension and Diabetes in a Primary Care Patient Sample.

BACKGROUND: Hypertension control and diabetes control are important for reducing cardiovascular disease burden. A growing body of research suggests an association between neighborhood environment and hypertension or diabetes control among patients engaged in clinical care. OBJECTIVE: To investigate whether neighborhood conditions (i.e., healthy food availability, socioeconomic status (SES), and crime) were associated with hypertension and diabetes control. DESIGN: Cross-sectional analyses using electronic medical record (EMR) data, U.S. Census data, and secondary data characterizing neighborhood food environments. Multivariate logistic regression analyses adjusted for potential confounders. Analyses were conducted in 2017. PARTICIPANTS: Five thousand nine hundred seventy adults receiving primary care at three Baltimore City clinics in 2010-2011. MAIN MEASURES: Census tract-level neighborhood healthy food availability, neighborhood SES, and neighborhood crime. Hypertension control defined as systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg. Diabetes control defined as HgbA1c < 7. KEY RESULTS: Among patients with hypertension, neighborhood conditions were not associated with lower odds of blood pressure control after accounting for patient and physician characteristics. However, among patients with diabetes, in fully adjusted models accounting for patient and physician characteristics, we found that patients residing in neighborhoods with low and moderate SES had reduced odds of diabetes control (OR = 0.74 (95% CI = 0.57-0.97) and OR = 0.75 (95% CI = 0.57-0.98), respectively) compared to those living in high-SES neighborhoods. CONCLUSIONS: Neighborhood disadvantage may contribute to poor diabetes control among patients in clinical care. Community-based chronic disease care management strategies to improve diabetes control may be optimally effective if they also address neighborhood SES among patients engaged in care.

Low-Income Black and Hispanic Children's Neighborhood Food Environments and Weight Trajectories in Early Childhood.

BACKGROUND: High obesity rates among young black and Hispanic children place them at a higher risk for adult obesity and its comorbidities. Neighborhoods with predominately racial and ethnic minority residents have fewer healthful food options, which may contribute to obesity disparities. Few studies have assessed the relationship between neighborhood food environments and obesity in this population. METHODS: Electronic health records from 2 pediatric primary care clinics serving predominately low-income, black, and Hispanic children were used to create a cohort of 3724 2- to 5-year olds, encompassing 7256 visits from 2007 to 2012 (mean 1.9 visits per patient, range: 1-5 visits per child). Longitudinal regression was used to model the association of mean body mass index z-score (BMI-z) over time and 3 measures of the neighborhood food environment: healthful food availability, availability of stores accepting the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) benefits, and fast food availability. RESULTS: Compared to peers in neighborhoods with no or few stores accepting WIC, children in neighborhoods with many WIC stores had higher BMI-z at age 2 years (average difference of 0.272; 95% confidence interval: 0.041-0.503; P = .021). No relationship was found for healthful food or fast food availability. Although children in neighborhoods with low fast food availability did not have statistically significantly different BMI-z at age 2 as compared to children in areas with high fast food availability, they did have a statistically significantly higher change in average BMI-z over time (0.006 per month, 0.000-0.012, P = .024). CONCLUSIONS: Access to WIC stores was associated with lower obesity rates and more healthful average BMI-z over time and represents a potentially important neighborhood food environment characteristic influencing racial/ethnic disparities in childhood obesity among young black and Hispanic children. More studies are needed to assess what aspects of WIC stores may underlie the observed association.

Association of Receipt of a Housing Voucher With Subsequent Hospital Utilization and Spending.

Importance: Although neighborhoods are thought to be an important health determinant, evidence for the relationship between neighborhood poverty and health care use is limited, as prior studies have largely used observational data without an experimental design. Objective: To examine whether housing policies that reduce exposure to high-poverty neighborhoods were associated with differences in long-term hospital use among adults and children. Design, Setting, and Participants: Exploratory analysis of the Moving to Opportunity for Fair Housing Demonstration Program, a randomized social experiment conducted in 5 US cities. From 1994 to 1998, 4604 families in public housing were randomized to 1 of 3 groups: a control condition, a traditional Section 8 voucher toward rental costs in the private market, or a voucher that could only be used in low-poverty neighborhoods. Participants were linked to all-payer hospital discharge data (1995 through 2014 or 2015) and Medicaid data (1999 through 2009). The final follow-up date ranged from 11 to 21 years after randomization. Exposures: Receipt of a traditional or low-poverty voucher vs control group. Main Outcomes and Measures: Rates of hospitalizations and hospital days, and hospital spending. Results: Among 4602 eligible individuals randomized as adults, 4072 (88.5%) were linked to health data (mean age, 33 years [SD, 9.0 years]; 98% female; median follow-up, 11 years). There were no significant differences in primary outcomes among adults randomized to receive a voucher compared with the control group (unadjusted hospitalization rate, 14.0 vs 14.7 per 100 person-years, adjusted incidence rate ratio [IRR], 0.95 [95% CI, 0.84-1.08; P = .45]; hospital days, 62.8 vs 67.0 per 100 person-years; IRR, 0.93 [95% CI, 0.77-1.13; P = .46]; yearly spending, $2075 vs $1977; adjusted difference, -$129 [95% CI, -$497 to $239; P = .49]). Among 11 290 eligible individuals randomized as children, 9118 (80.8%) were linked to health data (mean age, 8 years [SD, 4.6 years]; 49% female; median follow-up, 11 years). Receipt of a housing voucher during childhood was significantly associated with lower hospitalization rates (6.3 vs 7.3 per 100 person-years; IRR, 0.85 [95% CI, 0.73-0.99; P = .03]) and yearly inpatient spending ($633 vs $785; adjusted difference, -$143 [95% CI, -$256 to -$31; P = .01]) and no significant difference in hospital days (25.7 vs 28.8 per 100 person-years; IRR, 0.92 [95% CI, 0.77-1.11; P = .41]). Conclusions and Relevance: In this exploratory analysis of a randomized housing voucher intervention, adults who received a housing voucher did not experience significant differences in hospital use or spending. Receipt of a voucher during childhood was significantly associated with lower rates of hospitalization and less inpatient spending during long-term follow-up.

Bridging the Housing and Health Policy Divide: Lessons in Community Development from Memphis and Baltimore.

Governments and nonprofits routinely partner to launch place-based initiatives in distressed neighborhoods with the goal of stabilizing real estate markets, reclaiming vacant properties, abating public nuisances, and reducing crime. Public health impacts and outcomes are rarely the major policy drivers in the design and implementation of these neighborhood scale initiatives. In this article, we examine recent Health Impact Assessments in Baltimore, Maryland and Memphis, Tennessee to show how public health concepts, principles, and practices can be infused into existing and new programs and policies, and how public health programs can help to improve population health by addressing the upstream social determinants of health. We provide a portfolio of ideas and practices to bridge this classic divide of housing and health policy.