The impact of COVID-19 on psychiatric clinical encounters among low-income racially-diverse children.

BACKGROUND: There is a lack of longitudinal data to examine the impact of COVID-19 on all types of clinical encounters among United States, underrepresented BIPOC (Black, Indigenous, and people of color), children. This study aims to examine the changes in all the outpatient clinical encounters during the pandemic compared to the baseline, with particular attention to psychiatric encounters and diagnoses. METHOD: This study analyzed 3-year (January 2019 to December 2021) longitudinal clinical encounter data from 3,394 children in the Boston Birth Cohort, a US urban, predominantly low-income, Black and Hispanic children. Outcomes of interest were completed outpatient clinical encounters and their modalities (telemedicine vs. in person), including psychiatric care and diagnoses, primary care, emergency department (ED), and developmental and behavioral pediatrics (DBP). RESULTS: The study children's mean (SD) age is 13.9 (4.0) years. Compared to 2019, psychiatric encounters increased by 38% in 2020, most notably for diagnoses of adjustment disorders, depression, and post-traumatic stress disorders (PTSD). In contrast, primary care encounters decreased by 33%, ED encounters decreased by 55%, and DBP care decreased by 16% in 2020. Telemedicine was utilized the most for psychiatric and DBP encounters and the least for primary care encounters in 2020. A remarkable change in 2021 was the return of primary care encounters to the 2019 level, but psychiatric encounters fluctuated with spikes in COVID-19 case numbers. CONCLUSIONS: Among this sample of US BIPOC children, compared to the 2019 baseline, psychiatric encounters increased by 38% during 2020, most notably for the new diagnoses of adjustment disorder, depression, and PTSD. The 2021 data showed a full recovery of primary care encounters to the baseline level but psychiatric encounters remained sensitive to the pandemic spikes. The long-term impact of the pandemic on children's mental health warrants further investigation.

A Framework for Pursuing Child Health Equity in Pediatric Practice.

This article brings together several disparate frameworks to help outline a needed shift in pediatric practice to ensure child health equity. That shift involves moving from a commitment to equal care delivery to an explicit commitment to equitable health outcomes. The frameworks describe (1) the distinct domains of child health where inequity can be expressed, (2) the shortfalls of equal care delivery in meeting that promise, (3) a coherent typology of the barriers that drive health inequity and (4) a characterization of interventions as downstream, midstream, and upstream in nature.

Clarity on Disparity: Who, What, When, Where, Why, and How.

This article offers a framework of who, what, when, where, why, and how of health disparities that can serve as a systematic approach to move from description to understanding causes and taking action to ensure health equity.

Crossing the Quality Chasm and the Ignored Pillar of Health Care Equity.

Although there has been tremendous progress toward the aspiration of delivering quality health care, among the National Academy of Medicine's (previously Institute of Medicine) six pillars of quality (health care should be safe, effective, timely, patient-centered, efficient, and equitable), the last pillar, equity, has been largely ignored. Examples of how the quality improvement (QI) process leads to improvements are numerous and must be applied to the pillar of equity related to race/ethnicity and socioeconomic status. This article describes how equity should be addressed using the QI process.

Addressing the Long-term Effects of the COVID-19 Pandemic on Children and Families: A Report From the National Academies of Sciences, Engineering, and Medicine.

This Viewpoint discusses a consensus report from the National Academies of Sciences, Engineering, and Medicine (NASEM) that reviews the impact of COVID-19 on the health and well-being of children and families and what needs to be done to attenuate longer-term negative effects.

Enabling Factors Associated with Receipt of Interconception Health Care.

OBJECTIVES: Preventive health care between pregnancies may benefit future pregnancies and women's long-term health, yet such care is frequently incomplete. We used Andersen's Model of Health Services Use to identify factors associated with receipt of interconception care. METHODS: This secondary analysis uses data from a trial that recruited women from four health centers in the Baltimore metropolitan area. We used data on factors associated with Andersen's model reported up to 15 months postpartum. Factors included health history (diabetes, hypertension, prematurity), self-rated health, demographics (age, race/ethnicity, education, marital status, employment, income, parity), predisposing factors (depression, stress, social support), and enabling factors (usual place of care, personal doctor or nurse, insurance). Relative risk regression modeled the relationship between these factors and a dependent variable defined as completing both a postpartum visit and one subsequent health care visit. Models also accounted for time since birth, clustering by site, and trial arm. RESULTS: We included 376 women followed a mean of 272 days postpartum (SD 57), of whom 226 (60%) completed a postpartum and subsequent visit. Women were predominantly non-Hispanic Black (84%) and low income (50% household income < $20,000/year). In regression, two enabling factors were associated with increased receipt of care: having a personal doctor or nurse (RR 1.38, 95% CI 1.11-1.70) and non-Medicaid insurance (RR 1.64, 95% CI 1.09-2.56). CONCLUSIONS FOR PRACTICE: Enabling factors were associated with receipt of recommended care following birth. These factors may be modifiable components of efforts to improve care during this critical life course period.

The Uniqueness and Importance of Children in Addressing Health Disparities Across the Life Course: Implications for Research.

As the Eunice Kennedy Shriver National Institute of Child Health and Human Development's Division of Intramural Population Health Research celebrates its 50th Anniversary, it is appropriate to recognize great achievements in reducing child morbidity and mortality and increasing life expectancy. Unfortunately large racial/ethnic and socioeconomic health and healthcare disparities persist. This commentary suggests a framework to clarify the research and interventions needed to eliminate health disparities starting early in the life course.

Life Course Approaches to the Causes of Health Disparities.

Reducing health disparities requires an understanding of the mechanisms that generate disparities. Life course approaches to health disparities leverage theories that explain how socially patterned physical, environmental, and socioeconomic exposures at different stages of human development shape health within and across generations and can therefore offer substantial insight into the etiology of health disparities. Life course approaches are informed by developmental and structural perspectives. Developmental perspectives emphasize how socially patterned exposures to risk factors during sensitive life stages shift health trajectories, whereas structural perspectives emphasize how social identity and position within socially patterned environments disproportionately allocate risk factors and resources, resulting in altered health trajectories. We conclude that the science of health disparities will be advanced by integrating life course approaches into etiologic and intervention research on health disparities. The following 4 strategies are offered to guide in this process: (1) advance the understanding of multiple exposures and their interactions, (2) integrate life course approaches into the understanding of biological mechanisms, (3) explore transgenerational transmission of health disparities, and (4) integrate life course approaches into health disparities interventions.

Are Parent Activation and Health Literacy Distinct Concepts? A Study in Low Income Urban Populations.

Patient activation (the knowledge, confidence, willingness, and skills to manage one's healthcare) and health literacy have well-established associations with health and healthcare outcomes in adults. However, little is known about parent activation on behalf of children and its relation to health literacy. Our objective was to examine relations between parent activation, health literacy, and parent-provider relationship quality. We surveyed 316 Spanish- or English-speaking parents of publicly-insured patients of a general pediatrics clinic. Surveys included the Parent-Patient Activation Measure (P-PAM), the Newest Vital Sign (NVS), and parent-provider relationship measures. We used chi-square analyses and logistic regression to explore associations stratified by survey language. Spanish-speaking parents had significantly lower levels of both parent activation and health literacy compared with English-speaking parents (p<.001). Parent activation was not associated with health literacy, suggesting that they are distinct concepts. Because parent activation is a more easily modifiable trait than health literacy, it may present an opportunity to improve outcomes in less health literate populations. We did not find expected associations between parent activation, health literacy and parent-provider relationship quality. Further study is needed to understand how parent activation relates to pediatric outcomes, and if it is an appropriate intervention target to address child healthcare disparities in populations with limited health literacy.

Breaking the Intergenerational Cycle of Disadvantage: The Three Generation Approach.

Health disparities in the United States related to socioeconomic status are persistent and pervasive. This review highlights how social disadvantage, particularly low socioeconomic status and the health burden it brings, is passed from 1 generation to the next. First, we review current frameworks for understanding the intergenerational transmission of health disparities and provide 4 illustrative examples relevant to child health, development, and well-being. Second, the leading strategy to break the cycle of poverty in young families in the United States, the 2-generation approach, is reviewed. Finally, we propose a new 3-generation approach that must combine with the 2-generation approach to interrupt the intergenerational cycle of disadvantage and eliminate health disparities.

Child Health Disparities: What Can a Clinician Do?

Pediatric primary and specialty practice has changed, with more to do, more regulation, and more family needs than in the past. Similarly, the needs of patients have changed, with more demographic diversity, family stress, and continued health disparities by race, ethnicity, and socioeconomic status. How can clinicians continue their dedicated service to children and ensure health equity in the face of these changes? This article outlines specific, practical, actionable, and evidence-based activities to help clinicians assess and address health disparities in practice. These tools may also support patient-centered medical home recognition, national and state cultural and linguistic competency standards, and quality benchmarks that are increasingly tied to payment. Clinicians can play a critical role in (1) diagnosing disparities in one's community and practice, (2) innovating new models to address social determinants of health, (3) addressing health literacy of families, (4) ensuring cultural competence and a culture of workplace equity, and (5) advocating for issues that address the root causes of health disparities. Culturally competent care that is sensitive to the needs, health literacy, and health beliefs of families can increase satisfaction, improve quality of care, and increase patient safety. Clinical care approaches to address social determinants of health and interrupting the intergenerational cycle of disadvantage include (1) screening for new health "vital signs" and connecting families to resources, (2) enhancing the comprehensiveness of services, (3) addressing family health in pediatric encounters, and (4) moving care outside the office into the community. Health system investment is required to support clinicians and practice innovation to ensure equity.

Children, Families, and Disparities: Pediatric Provisions in the Affordable Care Act.

The Affordable Care Act has caused and continues to cause sweeping changes throughout the health system in the United States. Poorly explained, complex, controversial, confusing, and subject to continuous legal and regulatory definition, the law stands as a hallmark piece of legislation that will change the health sector in America forever. This article summarizes the Affordable Care Act with a focus on children, families, and disparities. Also provided is the context of the current system of health care coverage in the United States.

Promoting "Healthy Futures" to Reduce Risk Behaviors in Urban Youth: A Randomized Controlled Trial.

There is increasing evidence of the interconnection between educational and health outcomes. Unfortunately wide disparities exist by both socioeconomic status and race/ethnicity in educational and vocational success. This study sought to promote urban youths' career readiness as a way to reduce involvement in risk behaviors. Two hundred primarily African-American youth (ages 14-21) were recruited from a pediatric primary care clinic. Youth randomized to the intervention received three motivational interviewing sessions focused around expectations and planning for the future. Baseline and 6-month follow-up assessments included measures of career readiness and risk behavior involvement (i.e., physical fighting, alcohol and marijuana use). At 6-months, youth randomized to the intervention condition showed increased confidence in their ability to perform the behaviors needed to reach their college/career goals. Additionally, youth randomized to the intervention arm showed decreased fighting behavior (adjusted rate ratio: .27) and marijuana use (adjusted rate ratio: .61). Assisting urban youth in thinking and planning about their future holds promise as a way to reduce their involvement in risk behaviors. This study also demonstrated that motivational interviewing could be used to promote positive behaviors (i.e., career readiness).

Contraceptive service needs of women with young children presenting for pediatric care.

OBJECTIVES: The primary objective of this study is to characterize the need for contraceptive services and contraceptive method use among women with young children presenting to child health clinics. A secondary objective is to characterize the factors, including access to care and health needs, that exist in this population and to evaluate their association with contraceptive method use. STUDY DESIGN: This is a cross-sectional study of women with children under age 36 months presenting to four child health practices in the Baltimore, Maryland, area. Participating women completed a survey to assess desire for pregnancy, contraceptive method use and related characteristics. RESULTS: A total of 238 participants (82%) were in need of contraceptive services (fertile and not desiring pregnancy). Overall, 59 (25%) of women in need were not using a contraceptive method (unmet need) and 79 (33%) were using a highly effective method (implant or intrauterine device). Factors associated with lower odds of unmet need for contraceptive services included attendance at a routine postpartum visit and visiting a healthcare provider to discuss contraception after pregnancy. Approximately half of index pregnancies were unintended and this was the only health factor associated with greater odds of using of a highly effective contraceptive method. CONCLUSIONS: Most women presenting with young children for pediatric care indicated that they were not currently trying to become pregnant and reported current methods of pregnancy prevention that ranged from none to highly effective. Women who had not sought postpregnancy contraceptive care were more likely to have unmet need for contraceptive services. IMPLICATIONS: Child health clinics may be a novel site for providing contraceptive care to women with children as part of a strategy to reduce unplanned pregnancies.