"When You Look at This Chart, That Is Not My Whole Life": Caregiver Perspectives to Inform Improved Primary Care Practice and Outcomes.

OBJECTIVE: Worsening rates of infant and maternal mortality in the United States serve as an urgent call for multi-modal intervention. Infant Well Child Visits (WCVs) provide an opportunity for prevention, however not all infants receive the recommended schedule of visits, with infants of low-income and Black families missing a higher portion of WCVs. Due to diverse experiences and needs of under-resourced communities throughout the United States, caregiver voice is essential when designing improvement efforts. METHODS: Purposeful sampling and interviewing of 10 caregivers in Cincinnati, OH was performed by community peer researchers. Interview transcripts were evaluated by the research team, with identification of several important themes. RESULTS: Nine out of 10 caregivers self-identified as Black. All young children of the interviewed caregivers had Medicaid as their insurance provider. All interviews highlighted rich perspectives on caregiver hopes for their child, family, and selves. Establishing trust through empathy, shared decision making, and the nurturing of interpersonal patient-practitioner relationships is crucial for fostering a positive healthcare experience. Levels of mistrust was perceptibly high across several interviews, with lack of racial concordance between medical provider and family exacerbating the issue for some caregivers. Caregivers voiced a tendency to rely on family and community members for when to seek out health care for their children, and additionally cited racism and perceptions of being rushed or judged as barriers to seeking further care. CONCLUSION: This study emphasizes the importance of being community-informed when considering interventions. Prior research on the topic of missed WCV's often focused on material resource availability and limitations. While that was commented on by caregivers in this study as well, equal-if not more-attention was directed toward interpersonal relationship formation, the presence or absence of trust between practitioner and caregiver, and the importance of social-emotional support for caregivers. We highlight several opportunities for systemic improvements as well as future directions for research.

Beliefs and Motivations Regarding Early Shared Reading of Parents From Low-Income Households: A Qualitative Study.

OBJECTIVE: Parent-child "shared" reading is a catalyst for development of language and other emergent literacy skills. The American Academy of Pediatrics recommends that parents initiate shared reading as soon as possible after birth. Persistent disparities exist in reading resources, routines, and subsequent literacy outcomes, disproportionately impacting low-income households. We sought to understand beliefs, motivations, and experiences regarding shared reading during early infancy among parents from low-income households. METHODS: In this qualitative exploratory study, parents of infants aged 0 to 9 months from low-income households who had initiated shared reading ("readers") and those who had not ("nonreaders") were purposefully recruited to participate in individual semistructured virtual interviews. These interviews were coded using inductive thematic analysis by a 3-member team with diverse backgrounds. RESULTS: A total of 21 parents participated (57% readers, 86% mothers). Infants were 86% African American/Black, with a mean age of 3 months. Barriers noted by readers and nonreaders were i) competing demands on time, ii) lack of resources, and iii) parental mental health. An additional barrier noted solely by nonreaders was iv) it's too early/baby is not ready. Two benefits of reading were noted by both groups: 1) parents as child's first teachers and 2) reading catalyzes the child's development. Benefits noted exclusively by readers included 3) reading begets more reading, 4) bonding, 5) "it works," and 6) "two-for-one" shared reading (other children involved). CONCLUSIONS: This study provided insights into barriers and benefits regarding shared reading by socioeconomically disadvantaged parents of infants and has the potential to inform reading-related guidance and interventions.

Inpatient Screening of Parental Adversity and Strengths.

BACKGROUND AND OBJECTIVES: Social adversities, including health-harming social risks and adverse childhood experiences, contribute to poor outcomes after hospital discharge. Screening for social adversities is increasingly pursued in outpatient settings. Identifying and addressing such adversities has been linked to improved child outcomes. Screening for social adversities and strengths in the inpatient setting may contribute to better transitions from hospital to home. Our goal was twofold: 1. to use qualitative methods to understand parent perspectives around screening tools for potential use in inpatient settings; and 2. to develop a family-friendly inpatient screening tool for social adversity. METHODS: We used in-depth, cognitive qualitative interviews with parents to elicit their views on existing screening tools covering social adversities and strengths. We partnered with a local nonprofit to recruit parents who recently had a child hospitalized or visited the emergency department. There were 2 phases of the study. In the first phase, we used qualitative methods to develop a screening prototype. In the second phase, we obtained feedback on the prototype. RESULTS: We interviewed 18 parents who identified 3 major themes around screening: 1. factors that promote parents to respond openly and honestly during screening; 2. feedback about screening tools and the prototype; and 3. screening should include resources. CONCLUSIONS: Social adversity routinely affects children; hospitalization is an important time to screen families for adversity and potential coexisting strengths. Using qualitative parent feedback, we developed the family friendly Collaborate to Optimize Parent Experience screening tool.

"We know what's going on in our community": A qualitative analysis identifying community assets that deter gun violence.

Communities of color are disproportionately impacted by gun violence. Unlocking potential community-led solutions could be the key to quelling the gun violence epidemic and its impact on these communities. In this qualitative study, we explored community perspectives on local assets that may prevent and mitigate gun violence. We conducted semi-structured, in-depth interviews (n = 45) among individuals not directly involved in gun violence (i.e., shooting victim or perpetrator) despite having a high probability of being involved in gun violence in New Haven, CT. Participants were asked to describe social structures that may deter local gun violence. Here, we report emergent themes to preventing gun violence across multiple levels, including role models (interpersonal), social cohesion and home ownership (neighborhood), and community-based organizations (organizational). Our findings suggest that investments in stable housing, efforts to build social cohesion, access to community-based mental health services, and youth activities are needed to curb the drivers of community gun violence.

How Augmenting Reality Changes the Reality of Simulation: Ethnographic Analysis.

BACKGROUND: Simulation-based medical education (SBME) provides key medical training for providers to safely and ethically practice high-risk events. Augmented reality (AR)-enhanced simulation projects digital images of realistic examination findings into a participant's field of view, which allows nuanced physical examination findings such as respiratory distress and skin perfusion to be prominently displayed. It is unknown how AR compares to traditional mannequin (TM)-based simulation with regard to influencing participant attention and behavior. OBJECTIVE: The purpose of this study is to use video-based focused ethnography-a problem-focused, context-specific descriptive form of research whereby the research group collectively analyzes and interprets a subject of interest-to compare and categorize provider attention and behavior during TM and AR and provide suggestions for educators looking to delineate these 2 modalities. METHODS: Twenty recorded interprofessional simulations (10 TM, 10 AR) featuring a decompensating child were evaluated through video-based focused ethnography. A generative question was posed: "How do the attention and behavior of participants vary based on the simulation modality?" Iterative data collection, analysis, and pattern explanation were performed by a review team spanning critical care, simulation, and qualitative expertise. RESULTS: The attention and behavior of providers during TM and AR simulation clustered into three core themes: (1) focus and attention, (2) suspension of disbelief, and (3) communication. Participants focused on the mannequin during AR, especially when presented with changing physical examination findings, whereas in TM, participants focused disproportionately on the cardiorespiratory monitor. When participants could not trust what they were seeing or feeling in either modality, the illusion of realism was lost. In AR, this manifested as being unable to physically touch a digital mannequin, and in TM, participants were often unsure if they could trust their physical examination findings. Finally, communication differed, with calmer and clearer communication during TM, while AR communication was more chaotic. CONCLUSIONS: The primary differences clustered around focus and attention, suspension of disbelief, and communication. Our findings provide an alternative methodology to categorize simulation, shifting focus from simulation modality and fidelity to participant behavior and experience. This alternative categorization suggests that TM simulation may be superior for practical skill acquisition and the introduction of communication strategies for novice learners. Meanwhile, AR simulation offers the opportunity for advanced training in clinical assessment. Further, AR could be a more appropriate platform for assessing communication and leadership by more experienced clinicians due to the generated environment being more representative of decompensation events. Further research will explore the attention and behavior of providers in virtual reality-based simulations and real-life resuscitations. Ultimately, these profiles will inform the development of an evidence-based guide for educators looking to optimize simulation-based medical education by pairing learning objectives with the ideal simulation modality.

Participant engagement to develop report-back materials for personal air monitoring.

Background: Studies that measure environmental exposures in biological samples frequently provide participants their results. In contrast, studies using personal air monitors do not typically provide participants their monitoring results. The objective of this study was to engage adolescents who completed personal air sampling and their caregivers to develop understandable and actionable report-back documents containing the results of their personal air sampling. Methods: Adolescents and their caregivers who previously completed personal air sampling participated in focus groups to guide the development of report-back materials. We conducted thematic analyses of focus group data to guide the design of the report-back document and convened experts in community engagement, reporting study results, and human subjects research to provide feedback. Final revisions to the report-back document were made based on follow-up focus group feedback. Results: Focus groups identified critical components of an air-monitoring report-back document to include an overview of the pollutant being measured, a comparison of individual personal sampling data to the overall study population, a guide to interpreting results, visualization of individual data, and additional information on pollution sources, health risks, and exposure reduction strategies. Participants also indicated their desire to receive study results in an electronic and interactive format. The final report-back document was electronic and included background information, participants' results presented using interactive maps and figures, and additional material regarding pollution sources. Conclusion: Studies using personal air monitoring technology should provide research participants their results in an understandable and meaningful way to empower participants with increased knowledge to guide exposure reduction strategies.

Children from disadvantaged neighborhoods experience disproportionate injury from interpersonal violence.

BACKGROUND: Disparities in pediatric injury have been widely documented and are driven, in part, by differential exposures to social determinants of health (SDH). Here, we hypothesized that neighborhood socioeconomic deprivation and specific sociodemographic characteristics would be associated with interpersonal violence-related injury admission. METHODS: We conducted a retrospective cohort study of all patients ≤16 years, residing in Hamilton County, admitted to our level 1 pediatric trauma center. Residential addresses were geocoded to link admissions with a census tract-level socioeconomic deprivation index. Admissions were categorized as resulting from interpersonal violence or not - based on a mechanism of injury (MOI) of abuse or assault. The percentage of interpersonal violence-related injury admissions was compared across patient demographics and neighborhood deprivation index tertiles. These factors were then evaluated with multivariable regression analysis. RESULTS: Interpersonal violence accounted for 6.2% (394 of 6324) of all injury-related admissions. Interpersonal violence-related injury admission was associated with older age, male sex, Black race, public insurance, and living in tertiles of census tracts with higher socioeconomic deprivation. Those living in the most deprived tertile experienced 62.2% of all interpersonal violence-related injury admissions but only 36.9% of non-violence related injury admissions (p < 0.001). After adjustment, insurance and neighborhood deprivation accounted for much of the increase in interpersonal violence-related admissions for Black compared to White children. CONCLUSIONS: Children from higher deprivation neighborhoods, who are also disproportionately Black and publicly insured, experience a higher burden of interpersonal violence-related injury admissions. Level of evidence Level III.

Racial Fairness in Precision Medicine: Pediatric Asthma Prediction Algorithms.

PURPOSE: Quantify and examine the racial fairness of two widely used childhood asthma predictive precision medicine algorithms: the asthma predictive index (API) and the pediatric asthma risk score (PARS). DESIGN: Apply the API and PARS and evaluate model performance overall and when stratified by race. SETTING: Cincinnati, OH, USA. SUBJECTS: A prospective birth cohort of 590 children with clinically measured asthma diagnosis by age seven. MEASURES: Model diagnostic criteria included sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). ANALYSIS: Significant differences in model performance between Black and white children were considered to be present if the P-value associated with a t-test based on 100 bootstrap replications was less than .05. RESULTS: Compared to predictions for white children, predictions for Black children using the PARS had a higher sensitivity (.88 vs .57), lower specificity (.55 vs .83), higher PPV (.42 vs .33), but a similar NPV (.93 vs .93). Within the API and compared to predictions for white children, predictions for Black children had a higher sensitivity (.63 vs .53), similar specificity (.81 vs .80), higher PPV (.54 vs .28), and lower NPV (.86 vs .92). CONCLUSIONS: Overall, racial disparities in model diagnostic criteria were greatest for sensitivity and specificity in the PARS, but racial disparities existed in three of the four criteria for both the PARS and the API.

Relationships between socioeconomic deprivation and pediatric firearm-related injury at the neighborhood level.

BACKGROUND: Disparities in pediatric injury are widely documented and partly driven by differential exposures to social determinants of health (SDH). Here, we examine associations between neighborhood-level SDH and pediatric firearm-related injury admissions as a step to defining specific targets for interventions to prevent injury. METHODS: We conducted a retrospective review of patients 16 years or younger admitted to our Level I pediatric trauma center (2010-2019) after a firearm-related injury. We extracted patients' demographic characteristics and intent of injury. We geocoded home addresses to enable quantification of injury-related admissions at the neighborhood (census tract) level. Our population-level exposure variable was a socioeconomic deprivation index for each census tract. RESULTS: Of 15,686 injury-related admissions, 140 were for firearm-related injuries (median age, 14 years; interquartile range, 11-15 years). Patients with firearm-related injuries were 75% male and 64% Black; 66% had public insurance. Nearly half (47%) of firearm-related injuries were a result of assault, 32% were unintentional, and 6% were self-inflicted; 9% died. At the neighborhood level, the distribution of firearm-related injuries significantly differed by deprivation quintile ( p < 0.05). Children from the highest deprivation quintile experienced 25% of injuries of all types, 57% of firearm-related injuries, and 70% of all firearm-related injuries from assault. They had an overall risk of firearm-related injury 30 times that of children from the lowest deprivation quintile. CONCLUSION: Increased neighborhood socioeconomic deprivation is associated with more firearm-related injuries requiring hospitalization, at rates far higher than injury-related admissions overall. Addressing neighborhood-level SDH may help prevent pediatric firearm-related injury. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.

Exploratory Mixed-Methods Study of a Primary Care-Based Intervention Promoting Shared Reading During Infancy.

Parent-child "shared" reading can be a rich source of language exposure. Clinic-based programs, notably Reach Out and Read (ROR), are intended to enhance this. However, ROR has been traditionally introduced at 6 months and only recently expanded to younger ages. This study explored efficacy of an intervention delivered during pediatric well visits promoting shared reading prior to 6 months old, in terms of home reading attitudes and routines. The intervention group received children's books and anticipatory guidance about benefits of shared reading, whereas the control group received general age-related anticipatory guidance. Surveys were administered at the child's newborn (pre-intervention) and 6-month (post-intervention) well visits. Significant findings at 6 months included more frequent shared reading (P = .03), greater comfort reading at this age (P = .01), and greater importance attributed to shared reading (P = .04) in the intervention group relative to controls. These support the expansion of early literacy interventions such as ROR into early infancy.

Trends and Variation in the Gap Between Current and Anticipated Life Satisfaction in the United States, 2008-2020.

Objectives. To describe national- and county-level trends and variation in a novel measure of hope. Methods. Using data from the Gallup National Health and Well-Being Index (n = 2 766 728), we summarized the difference between anticipated life satisfaction (ALS) and current life satisfaction (CLS), measured by the Cantril Self-Anchoring Scale, for each year from 2008 to 2020 and by county over two 5-year periods in the United States. Results. Across all years, there was a significant positive trend in the difference between ALS and CLS for the nation (P = .024), which remained positive but not significant when we excluded 2020. Maintenance of ALS with a decrease in CLS drove the 2020 increase. From 2008-2012 to 2013-2017, 14.5% of counties with 300 or more responses (n = 599) experienced an increase in the difference of more than 1 SD, whereas 13.9% experienced a more than 1 SD decrease. Fifty-two counties experienced decreases in ALS and CLS. Conclusions. Responding to trends in the gap between ALS and CLS at national and local levels is essential for the collective well-being of our nation, especially as we navigate and emerge from crisis.

Pediatricians Contributing to Poverty Reduction Through Clinical-Community Partnership and Collective Action: A Narrative Review.

Poverty affects child health and well-being in short- and long-term ways, directly and indirectly influencing a range of health outcomes through linked social and environmental challenges. Given these links, pediatricians have long advocated for poverty reduction in both clinical settings and society. Pediatricians and others who work in pediatric settings are well-suited to address poverty given frequent touchpoints with children and families and the trust that develops over repeated encounters. Many pediatricians also recognize the need for cross-sector engagement, mobilization, and innovation in building larger collaborative efforts to combat the harmful effects of poverty. A range of methods, like co-design, community organizing, and community-engaged quality improvement, are necessary to achieve measurable progress. Moreover, advancing meaningful representation and inclusion of those from underrepresented racial and ethnic minority groups will augment efforts to address poverty within and equity across communities. Such methods promote and strengthen key clinical-community partnerships poised to address poverty's upstream root causes and its harmful consequences downstream. This article focuses on those clinical-community intersections and cross-sector, multi-disciplinary programs like Medical-Legal Partnerships, Medical-Financial Partnerships, clinic-based food pantries, and embedded behavioral health services. Such programs and partnerships increase access to services difficult for children living in poverty to obtain. Partnerships can also broaden to include community-wide learning networks and asset-building coalitions, poised to accelerate meaningful change. Pediatricians and allied professionals can play an active role; they can convene, catalyze, partner, and mobilize to create solutions designed to mitigate the harmful effects of poverty on child health.

Contextual Factors Affecting Implementation of In-hospital Pediatric CPR Quality Improvement Interventions in a Resuscitation Collaborative.

INTRODUCTION: Pediatric quality improvement (QI) collaboratives are multisite clinical networks that support cooperative learning. Our goal is to identify the contextual facilitators and barriers to implementing QI resuscitation interventions within a multicenter resuscitation collaborative. METHODS: A mixed-methods evaluation of the contextual facilitators and barriers to implementation of a resuscitation QI bundle. We administered a quantitative questionnaire, the Model for Understanding Success in Quality (MUSIQ), to the Pediatric Resuscitation Quality (pediRES-Q) Collaborative. Its primary goal is to optimize the care of children who experience in-hospital cardiac arrest through a resuscitation QI bundle. We also conducted semistructured phone interviews with site primary investigators adapted from the Consolidated Framework for Implementation Research qualitative interview guide. RESULTS: All 13 actively participating US sites completed the MUSIQ questionnaire. Total MUSIQ scores ranged from 86.0 to 140.5 (median of 118.7, interquartile range 103.6-124.5). Evaluation of the QI team subsection noted a mean score of 5.5 for low implementers and 6.1 for high implementers (P = 0.02). We conducted 8 interviews with the local QI team leadership. Contextual facilitators included a unified institutional approach to QI, a fail forward climate, leadership support, strong microculture, knowledge of other organizations, and prioritization of goals. Contextual barriers included low team tenure, no specific allocation of resources, lack of formalized QI training, and lack of support and buy-in by leaders and staff. CONCLUSIONS: Using mixed methods, we identified an association between the local QI team's strength and the successful implementation of the QI interventions.

Socioeconomic and Racial Disparities in Diabetic Ketoacidosis Admissions in Youth With Type 1 Diabetes.

OBJECTIVE: We sought to determine whether census tract poverty, race, and insurance status were associated with the likelihood and severity of diabetic ketoacidosis (DKA) hospitalization among youth with type 1 diabetes (T1D). METHODS: We conducted a retrospective population-based cohort study using Cincinnati Children's Hospital electronic medical record (EMR) data from January 1, 2011, to December 31, 2017, for T1D patients ≤18 years old. The primary outcome was admission for DKA. Secondary outcomes included DKA severity, defined by initial pH and bicarbonate, and length of stay. Exposures were the poverty rate for the youth's home census tract, parent-reported race, and insurance status. We used multivariable logistic regression to analyze effects on odds of admission. RESULTS: We identified 439 patients with T1D; 152 were hospitalized. The cohort was 48% female, 25% Black, and 36% publicly insured; the median age was 14 years. For every 10% increase in a youth's census tract poverty rate, the adjusted odds of admission increased by 22% (95% CI, 1.03-1.47). Public insurance status was associated with DKA admission (adjusted odds ratio [AOR], 2.71, 95% CI, 1.62-4.55) while race was not. There were no clinically meaningful differences in pH or bicarbonate by census tract poverty, race, or insurance status; however, Black patients experienced differences in care (eg, longer length of stay). CONCLUSION: Youth with T1D living in high poverty areas and on public insurance were significantly more likely to be admitted for DKA. Severity upon presentation was similar across exposures. Understanding contextual mechanisms by which disparities emerge will inform changes aimed at equitably improving care.

Seven practices for pursuing equity through learning health systems: Notes from the field.

INTRODUCTION: Despite learning health systems' focus on improvement in health outcomes, inequities in outcomes remain deep and persistent. To achieve and sustain health equity, it is critical that learning health systems (LHS) adapt and function in ways that directly prioritize equity. METHODS: We present guidance, including seven core practices, borne from theory, evidence, and experience, for actors within LHS pursuing equity. RESULTS: We provide a foundational definition of equity. We then offer seven core practices for how LHS may effectively pursue equity in health: establish principle, measure for equity, lead from lived experience, co-produce, redistribute power, practice a growth mindset, and engage beyond the healthcare system. We include three use cases that illustrate ways in which we have begun to center equity in the work of our own LHS. CONCLUSION: The achievement of equity requires real transformation at individual, institutional, and structural levels and requires sustained and persistent effort.

Factors Associated With Residential Relocation and Effects on Early Childhood Development in a Low-Income Home Visitation Population.

Residential relocation (RR) is associated with behavior problems and cognitive delays in school-age children. Little is known regarding effects of RR on early childhood development. The data from this study were collected from 2011 to 2016 through the Cincinnati Home Injury Prevention and Literacy Promotion Trial. The purpose of the current study was to identify factors associated with RR and determine effects of RR on early childhood development in a cohort of mother/child dyads (n = 424). High RR was relocating ≥ 3 times over the 24-month study period. Differences in baseline characteristics and early childhood development, measured by the Ages and Stages Questionnaire (ASQ) and MacArthur Bates Communicative Development Inventory, according to relocations, were estimated by negative binomial regression and logistic regression, respectively. Participants moved on average 1.46 times over 24 months. Relocations decreased by 0.05 for each year of increasing maternal age. Mothers with college degrees moved 0.72 fewer times than those with a high school diploma or less. Mothers living alone moved 0.47 fewer times than their counterparts. Mothers who could not count on someone to loan them $1000 and those with food insecurity more (0.41) than their counterparts (0.50). Odds of scoring in the bottom-tertile for the communication domain of the ASQ was significantly higher in those relocating ≥ 3 times. High RR was associated with concern for delayed language development at 24-month follow-up in some, but not all models. Early intervention may be more successful if primary care physicians and community health professionals collaborate to link families at risk of high RR to relevant community based resources.

Cultivating social relationships and disrupting social isolation in low-income, high-disparity neighbourhoods in Ohio, USA.

Social isolation undermines health. Inequities in social networks exist due to historical and contemporary practices of socioeconomic and racial segregation. Thus, lower income and minority families are less likely to have the number, strength, and variety of social connections as higher income and white families. Therefore, social isolation may contribute to inequities in health and well-being across socioeconomic and racial groups. Disrupting social isolation by strengthening social networks may be a meaningful way to equitably improve population health. In this study we aimed to better understand the factors that influence the formation and sustainment of social connections in neighbourhoods experiencing a disproportionate burden of social needs and poor health outcomes. Participants were recruited through our community-academic partnership, Healthy Homes (HH). Healthy Homes serves families with pregnant women and/or children <6 years in two low-income, high-morbidity neighbourhoods, focusing on supporting families' needs and hopes. Between October 2016 and April 2017, we conducted in-depth qualitative interviews (n = 20) with English-speaking mothers and grandmothers of children under <6 years. Interviews were audio-recorded, transcribed verbatim and independently coded. After applying an a priori code list, we conducted emergent coding to identify additional themes. Themes focused on the social environment, including social connections and social isolation, among vulnerable populations in included neighbourhoods. Families want connection to one another and to resources but look to others to facilitate those connections. Families may want or need social connections but do not engage if it means sacrificing their values or sense of self-worth. These findings provide a deeper understanding of the factors that might allow us to disrupt social isolation by building relationships in communities that face social and health inequities.