Using Quality Improvement as a Mechanism for Fostering Partnerships and Promoting Equity in a Health System Change Model.

PURPOSE: Quality improvement (QI) processes provide a framework for systematically examining target outcomes and what changes can be made to result in improvement and ensure equity. We present a case study of how QI processes were used as a means of partnership building to enhance equity in designing materials for a Medicaid pilot program, North Carolina Integrated Care for Kids (NC InCK). DESCRIPTION: The NC InCK model addresses social determinants of health by providing structured care integration across core child health and social service areas and using an alternative payment model to incentivize high quality child outcomes. During the two-year planning period prior to the NC InCK model launch, we used Plan-Do-Study-Act (PDSA) cycles to conduct usability testing as a QI strategy for a component of the NC InCK model: the Shared Action Plan (SAP). ASSESSMENT: We conducted usability testing with four Family Council members, nine care managers, and one physician. Participants reviewed the SAP and provided feedback via a survey. After reviewing feedback with InCK leadership and the Family Council, we implemented recommendations that led to a SAP that uses clear and accessible language, that highlights family strengths and family-identified goals, and that is distinct from other care management plans. CONCLUSION: Usability testing forced refinement of materials before NC InCK launched, created opportunities for building and enhancing community partnerships and promoted equity within the NC InCK team and Family Council by considering multiple perspectives when deciding on SAP revisions.

Association of Housing Stress With Child Maltreatment: A Systematic Review.

Child maltreatment is a significant public health issue in the United States. Understanding key risk factors for child maltreatment is critical to informing effective prevention. Poverty is an established risk factor for child maltreatment. However, recent research indicates that material hardship (i.e., difficulties meeting basic needs) may serve as a more direct measure of the way in which poverty affects daily life. One form of material hardship that is common among families is housing stress. Previous reviews have summarized the existing literature regarding the association of economic insecurity with child maltreatment, but no reviews have synthesized and critically evaluated the literature specific to the association of various types of housing stress with child maltreatment. We conducted a systematic search of multiple electronic databases to identify peer-reviewed studies conducted in the U.S. regarding the association of housing stress with child maltreatment. We identified 21 articles that used nine distinct measures of housing stress including homelessness or eviction, homeless or emergency shelter stays, foreclosure filing, housing instability, inadequate housing, physical housing risk, living doubled-up, housing unaffordability, and composite housing stress indicators. Overall, results from this body of literature indicate that housing stress is associated with an increased likelihood of caregiver or child self-reported maltreatment, child protective services (CPS) reports, investigated and substantiated CPS reports, out-of-home placements, and maltreatment death. Additional theory-driven research is needed to further our understanding of the contribution of specific types of housing stress to risk for specific types of maltreatment.

Training Public Health Students in Racial Justice and Health Equity : A Systematic Review.

In an attempt to move the field of public health from documenting health disparities to acting to rectify them, in 2001, the American Public Health Association (APHA) recognized racism as a fundamental cause of racial health disparities. Both APHA and the Council on Education for Public Health have moved to incorporate new competencies in health equity for public health professionals. As schools and programs of public health work to establish curricular offerings in race and racism, a need exists to identify approaches currently in use that can be replicated, adapted, and scaled. This systematic review sought to identify pedagogical methods and curricula that exist to support the training of US public health students in understanding racism as a structural determinant of health. We found 11 examples from peer-reviewed literature of curricula, lessons, and competencies that have been developed by public health faculty and departments since 2006. The articles discussed a range of approaches to teaching about structural racism in public health, suggesting that little consensus may exist on how to best teach this material. Furthermore, we found little rigorous evaluation of these teaching methods and curricula. The results of this review suggest future research is needed on public health pedagogy on structural racism.

The association between early reports to Child Protective Services and developmental trajectories through middle childhood.

BACKGROUND: Longitudinal studies on resilience among children who have experienced maltreatment indicate that resilience is multi-dimensional. However, most research consolidates diverse developmental domains comprising resilience into a single score, which does not allow for detection of potentially heterogeneous associations between risk factors and outcomes of resilience processes. OBJECTIVE: This study seeks to improve our understanding of the association between early child maltreatment and development through middle childhood (6-12 years) using individual domains considered to be outcomes of resilience processes. PARTICIPANTS AND SETTING: Participants are 499 children from the Longitudinal Studies of Child Abuse and Neglect. METHODS: We used latent growth curve models to explore patterns of socialization and daily living skills, and internalizing and externalizing behaviors - outcomes of resilience processes - across three time points in middle childhood, and their association with early maltreatment, defined as referral to Child Protective Services (CPS) before age 6. RESULTS: In fully adjusted models, children experiencing early maltreatment had poorer baseline scores in activities of daily living (-4.22, 95% CI [-7.38, -1.46]) and externalizing behavior (2.95, 95% CI [1.05, 4.86]), but maltreatment was not associated with change over time in these domains. However, maltreatment was associated with increases in internalizing behavior over time (0.42, 95% CI [0.06, 0.77]). CONCLUSION: Heterogeneity in patterns of association between maltreatment and outcomes of resilience processes support the utility of examining developmental domains individually, versus as a composite, to identify specific targets for intervention.