Addressing adverse social determinants of health in pediatric primary care: Study protocol for a hybrid type 2 effectiveness-implementation randomized controlled trial in two national pediatric practice-based research networks.

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.

The Association Between Racial Discrimination, Race, and Social Class With Health Among US Children.

OBJECTIVES: To assess the association between racial discrimination, race and ethnicity, and social class with child health and unmet health care needs among children in the United States (US). METHODS: We used a nationally representative sample of children aged 0 to 17 from the 2018-2019 National Survey of Children's Health. Bivariate and multivariable logistic regression were used to test associations between measures of discrimination, social class (income, employment, and education), and race and ethnicity with overall child health and unmet health care needs controlling for covariates identified a priori. RESULTS: Overall, 90.3% of children (n = 59,964) had excellent/very good overall health; 3.1% had unmet health care needs. Black, non-Hispanic children had 8.9 times the odds of having experienced racial discrimination compared to White, non-Hispanic children (95% confidence interval [CI], 7.0-11.4). Having special health care needs was significantly associated with greater odds of racial discrimination (OR 2.3; 95% CI, 1.9-2.8). In multivariable models, underrepresented race and ethnicity groups, lower household income level, and lower caregiver education were significantly associated with poorer overall child health. Conversely, experiencing discrimination was not significantly associated with excellent/good overall child health (adjusted odds ratios [aORs], 0.8; 95% CI, 0.6-1.1) Racial discrimination (aOR 2.7; 95% CI, 1.9-4.0) and lower household income (aOR 2.6; 95% CI, 1.8-3.5) were associated with significantly greater odds of unmet health care needs. CONCLUSION: Race and ethnicity and low social class were significantly associated with worse overall health while racial discrimination and low-income were associated with more unmet health care needs. These findings underscore the importance of policy and health care system innovations that address the effects of racism and poverty on child health.

Supplemental Nutrition Assistance Program participation and health care expenditures in children.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) has well-established positive impacts on child health outcomes, including increased birth weight and decreased likelihood of underweight status. Studies in adult populations suggest that SNAP is associated with lower health care costs, although less is known in children. METHODS: Retrospective analysis of U.S. children (age <18 years) living in low-income households (< 200% of the federal poverty level) in the 2013-2017 Medical Expenditure Panel Survey. We used multivariable regression, adjusting for sociodemographic and clinical covariates, to model the effect of continuous SNAP enrollment on health expenditures as compared to non-enrollees at 12 and 24 months. RESULTS: The sample included 5,626 children, of whom 49.2% consistently received SNAP for the entire two-year survey period. Compared with SNAP non-recipients, SNAP-recipient households more often had incomes below 100% FPL (78.3% vs 37.9%), and children in SNAP-recipient households were more often publicly insured (94.9% vs 64.5%). Unadjusted expenditures were lower for children in SNAP-recipient households at 12 ($1222 vs $1603) and 24 months ($2447 vs $3009). However, when adjusting for sociodemographic and clinical differences, no statistically significant differences in health care expenditures, including emergency department, inpatient, outpatient, and prescription costs, were identified. CONCLUSION: SNAP participant children experience heightened social hardships across multiple domains. There were no differences in short term health care costs based on SNAP enrollment when accounting for differences in sociodemographic and clinical factors. Despite demonstrated child health benefits, we found that sustained enrollment in SNAP over a two-year period did not generate significant short- term health care cost reductions. Our findings suggest that although SNAP is intended to act as a benefit towards the health and well-being of its recipients, unlike among adults, it may not reduce health care costs among children.

Clinical Approaches to Reducing Material Hardship Due to Poverty: Social Risks/Needs Identification and Interventions.

The field of pediatrics has pioneered approaches to mitigating poverty's harmful effects on children's health and development. Clinical interventions for systematically addressing material hardships due to poverty within the context of pediatric care delivery, however, are still in their infancy. Since the American Academy of Pediatrics published its policy statement on Child Health and Poverty in the United States in 2016, interest has surged in the development and implementation of care models that systematically identify and address social risks and/or social needs. This article explores this major shift in interest, research, and investment in such interventions within pediatric care. We provide an overview of current screening and referral models for addressing poverty-related social factors and explore the strengths and weaknesses of these varied approaches. We summarize the current evidence supporting such clinical approaches, and comment on the importance of multi-sectoral partnerships in addressing families' and communities' needs. Lastly, we propose future directions for research and pediatric practice that may enhance the uptake of social risks/needs interventions and bolster the evidence of their effectiveness. Though clinical approaches for addressing material hardship may be limited by an insufficient social safety net and other barriers, interventions to identify and address families' social risks and social needs have the potential to combat poverty's impact on children and advance health equity.

Impact of an On-Site Versus Remote Patient Navigator on Pediatricians' Referrals and Families' Receipt of Resources for Unmet Social Needs.

Background: Patient navigation is increasingly being used by pediatric health care delivery systems to address patients' unmet social needs. However, it is not known whether navigators working remotely can be as effective at linking families to community resources as on-site navigators. The aim of this study was to assess whether a patient navigator located on-site versus remotely is more likely to receive referrals from clinicians, successfully follow-up with patients, and assist families with enrollment in social needs resources. Methods: A patient navigator worked on-site and remotely as she divided her time between 4 federally qualified health centers (FQHCs) from May 2015 to June 2019. We conducted a 1-sample test of proportion comparing the proportion of on-site referrals made with the proportion of the week spent in each FQHC. To assess the impact of on-site versus remote referrals on number of contacts with a family, we conducted a 2-sample t test. We used chi-square testing to assess the effect of on-site versus remote status on resource enrollment. Results: Of the referrals (N = 414) made to the patient navigator, the majority were made through the electronic health record (83%) versus in person (17%) (P < .0001). When the navigator was on-site, significantly more referrals were made than expected (45% vs 29%, P < .0001). Between remote and on-site referral groups, there was no significant difference in number of contact points (1.0 vs 1.1 points, P = .32) or in the proportion of families who received a resource (4.6% vs 5.1%, P = .31). Conclusion: Our results indicate that clinicians were significantly more likely to refer families to patient navigation if the navigator was on-site. The likelihood of having contact with the navigator and enrolling in a resource, however, did not differ between families referred when the patient navigator was on-site compared with remote.