Associations Between Early-Life Adversity, Ambient Air Pollution, and Telomere Length in Children.

OBJECTIVE: Examine the independent associations and interaction between early-life adversity and residential ambient air pollution exposure on relative buccal telomere length (rBTL). METHODS: Experiences of abuse, neglect, household challenges, and related life events were identified in a cross-sectional sample of children ages 1-11 years (n = 197) using the 17-item Pediatric ACEs and Related Life Event Screener (PEARLS) tool. The PEARLS tool was analyzed both as a total score and across established domains (Maltreatment, Household Challenges, and Social Context). Ground-level fine particulate matter (PM 2.5 ) concentrations were matched to residential locations for the one and twelve months prior to biospecimen collection. We used multivariable linear regression models to examine for independent associations between continuous PM 2.5 exposure and PEARLS score/domains with rBTL. Additionally, effect modification by PEARLS scores and domains on associations between PM 2.5 exposure and rBTL was examined. RESULTS: Study participants were 47% girls, with mean age = 5.9 years [standard deviation: 3.4] median reported PEARLS score of 2 [interquartile range (IQR): 4], median 12-month prior PM 2.5 concentrations of 11.8 µg/m 3 [IQR: 2.7], median 1-month prior PM 2.5 concentrations of 10.9 µg/m 3 [IQR: 5.8], and rBTL of 0.1 [IQR: 0.03]. Mean 12-month prior PM 2.5 exposure was inversely associated with rBTL (ß = -0.02, 95% CI: -0.04, -0.01). While reported PEARLS scores and domains were not independently associated with rBTL, we observed a greater decrement in rBTL with increment of average annual PM 2.5 as reported Social Context domain items increased (p-interaction<0.05). CONCLUSION: Our results suggest that adverse Social Context factors may accelerate the association between chronic PM 2.5 exposure on telomere shortening during childhood.

Smoking Cessation Support in the Context of Other Social and Behavioral Needs in Community Health Centers.

BACKGROUND: Cigarette smoking rates remain disproportionately high among low income populations with unmet social and behavioral health needs. To address this problem, we sought to develop and evaluate the feasibility, acceptability, and preliminary effectiveness of a novel smoking cessation program for community health centers that serve these populations. METHODS: We implemented a randomized pilot trial of two smoking cessation programs in three county operated community health center (CHC) sites: (1) a systematic assessment of smoking habits and standard tools to assist with smoking cessation counseling ("Enhanced Standard Program" or ESP), and (2) another that added a structured assessment of social and behavioral barriers to smoking cessation, ("Connection to Health for Smokers" or CTHS). Clinical outcomes were evaluated between 10 to 16 weeks, supplemented with interviews of patient participants and health care team members. RESULTS: 141 adults were randomized and 123 completed the intervention (61 in ESP, 62 in CTHS). At follow-up, over half of participants reported ≥1 quit attempts (59.7% ESP and 56.5% CTHS; adjusted p = .66) while more in ESP (24.6% vs. 12.9%) were documented as not smoking in the last 7 days (adjusted p = 0.03). In addition to being in ESP, predictors of smoking cessation included higher baseline confidence in ability to quit (p = 0.02) and more quit attempts during the study (p = 0.04). Health care teams, however, generally preferred the more comprehensive approach of CTHS. CONCLUSION: Lessons learned from this pilot study may inform the development of effective smoking cessation programs for CHCs that combine elements of both interventions.

Adverse Childhood Experiences and Related Events are Associated with Asthma Symptoms in Children.

OBJECTIVE: To examine the association between adverse childhood experiences (ACEs) and related events and asthma symptom burden in children. METHODS: This is a cross-sectional study of baseline data from 147 participants with asthma from a cohort of children enrolled in the Pediatric ACEs Screening and Resiliency Study. Participants completed the PEdiatric ACEs and Related Life Events Screener (PEARLS) tool, a 17-item questionnaire, capturing 3 domains of childhood adversity-child maltreatment, household challenges, and social context. Asthma symptom burden was assessed using the International Study of Asthma and Allergies in Childhood core questionnaire, which asks participants to identify the presence and frequency of severe wheezing that limits speech, wheezing with exercise, nocturnal wheezing, and nocturnal cough in the last 12 months. Using multivariable logistical regression models, we examined the relationship between reported PEARLS and asthma symptoms. RESULTS: Of children with asthma, 86% reported at least 1 adversity, with 48% reporting 4 or more. The odds of severe wheeze limiting speech increased by 19% with each additional reported adversity captured by the PEARLS tool (95% confidence intervals (CI) 1.01-1.41). Increasing PEARLS scores were also associated with 16% increased odds of reporting wheeze with exercise (95% CI 1.03-1.31). Wheezing with exercise was associated with the household challenges domain (odds ratio (OR) 1.34; 95% CI 1.05-1.72), while severe wheeze limiting speech was associated with the social context domain (OR 1.75; 95%CI 1.02-3.02). CONCLUSIONS: Childhood adversities are associated with increased asthma symptom burden, suggesting the tool may be helpful in identifying children at risk for poorly controlled asthma.

Associations between Social Adversity and Biomarkers of Inflammation, Stress, and Aging in Children.

BACKGROUND: Prior work has found relationships between childhood social adversity and biomarkers of stress, but knowledge gaps remain. To help address these gaps, we explored associations between social adversity and biomarkers of inflammation (interleukin-1ß [IL-1ß], IL-6, IL-8, tumor necrosis factor-alpha [TNF-α], and salivary cytokine hierarchical "clusters" based on the three interleukins), neuroendocrine function (cortisol, cortisone, dehydroepiandrosterone, testosterone, and progesterone), neuromodulation (N-arachidonoylethanolamine, stearoylethanolamine, oleoylethanolamide, and palmitoylethanolamide), and epigenetic aging (Pediatric-Buccal-Epigenetic clock). METHODS: We collected biomarker samples of children ages 0-17 recruited from an acute care pediatrics clinic and examined their associations with caregiver-endorsed education, income, social risk factors, and cumulative adversity. We calculated regression-adjusted means for each biomarker and compared associations with social factors using Wald tests. We used logistic regression to predict being in the highest cytokine cluster based on social predictors. RESULTS: Our final sample included 537 children but varied based on each biomarker. Cumulative social adversity was significantly associated with having higher levels of all inflammatory markers and with cortisol, displaying a U-shaped distribution. There were no significant relationships between cumulative social adversity and cortisone, neuromodulation biomarkers or epigenetic aging. CONCLUSION: Our findings support prior work suggesting that social stress exposures contribute to increased inflammation in children. IMPACT: Our study is one of the largest studies examining associations between childhood social adversity and biomarkers of inflammation, neuroendocrine function, neuromodulation, and epigenetic aging. It is one of the largest studies to link childhood social adversity to biomarkers of inflammation, and the first of which we are aware to link cumulative social adversity to cytokine clusters. It is also one of the largest studies to examine associations between steroids and epigenetic aging among children, and one of the only studies of which we are aware to examine associations between social adversity and endocannabinoids among children. CLINICAL TRIAL REGISTRATION: NCT02746393.

Revising the Logic Model Behind Health Care's Social Care Investments.

Policy Points This article summarizes recent evidence on how increased awareness of patients' social conditions in the health care sector may influence health and health care utilization outcomes. Using this evidence, we propose a more expansive logic model to explain the impacts of social care programs and inform future social care program investments and evaluations.

A novel approach to understanding and assessing the emotional side of type 1 diabetes: The Type 1-Diabetes Distress Assessment System.

AIMS: To describe the development of a novel, conceptually sound instrument with contemporary content for assessing diabetes distress (DD) among adults with type 1 diabetes. METHODS: Qualitative interviews with 15 adults and 7 clinicians were used to develop Core (intensity of DD emotional burden) and primary Source (key DD contributors) items. These were administered to a national sample recruited from the TCOYD Research Registry, T1D Exchange and our previous studies. Exploratory and confirmatory factor analyses were undertaken, along with reliability and construct validity studies, and cut-point analyses to determine elevated DD. RESULTS: Analyses based on 650 respondents yielded an 8-item Core DD scale (α = 0.95) and 10 2- or 3-item DD Source Scales (α range = 0.53-0.88): Financial Worries, Interpersonal Challenges, Management Difficulties, Shame, Hypoglycemia Concerns, Healthcare Quality, Lack of Diabetes Resources, Technology Challenges, Burden to Others and Worries about Complications. Core and Source scores were significantly associated with criterion variables: Higher DD scores were significantly linked with higher HbA1C , more frequent episodes of severe hypoglycaemia, missed boluses, and poorer quality of life (p > 0.001). A ≥2.0 scale cut-point to define elevated DD is suggested. CONCLUSIONS: The new T1-Diabetes Distress Assessment System demonstrated good reliability and validity, and with measures of both Core emotional burden and Sources of DD, it provides a contemporary, flexible and practical approach to assessing DD that can be used seamlessly to inform intervention for clinicians and researchers.

Screening for Financial Hardship: Comparing Patient Survey Responses Using Two Different Screening Tools.

BACKGROUND: Healthcare delivery organizations are increasingly screening patients for social risks using tools that vary in content and length. OBJECTIVES: To compare two screening tools both containing questions related to financial hardship. DESIGN: Cross-sectional survey. PARTICIPANTS: Convenience sample of adult patients (n = 471) in three primary care clinics. MAIN MEASURES: Participants randomly assigned to self-complete either: (1) a screening tool developed by the Centers for Medicare & Medicaid Services (CMS) consisting of six questions on financial hardship (housing stability, housing quality, food security, transportation security, utilities security); or (2) social and behavioral risk measures recommended by the National Academy of Medicine (NAM), including one question on financial hardship (financial strain). We compared patient acceptability of screening, positive screening rates for financial hardship, patient interest in assistance, and self-rated health. RESULTS: Ninety-one percent of eligible/interested patients completed the relevant survey questions to be included in the study (N = 471/516). Patient acceptability was high for both tools, though more participants reported screening was appropriate when answering the CMS versus NAM questions (87% vs. 79%, p = 0.02). Of respondents completing the CMS tool, 57% (132/232) reported at least one type of financial hardship; on the NAM survey, 52% (125/239) reported financial hardship (p = 0.36). Nearly twice as many respondents indicated interest in assistance related to financial hardship after completing items on the CMS tool than on the NAM question (39% vs. 21%, p < 0.01). CONCLUSIONS: Patients reported high acceptability of both social risk assessment tools. While rates of positive screens for financial hardship were similar across the two measures, more patients indicated interest in assistance after answering questions about financial hardship on the CMS tool. This might be because the screening questions on the CMS tool help patients to appreciate the types of assistance related to financial hardship that may be available after screening. Future research should assess the validity and comparative validity of individual measures and measure sets. Tool selection should be based on setting and population served, screening goals, and resources available.

Training peers to deliver mental health support to adults with type 1 diabetes using the REACHOUT mobile app.

AIMS: While peer support research is growing in the Type 1 diabetes (T1D) community, the peer supporter training (PST) process is rarely documented in detail. This study provides a comprehensive description of PST and evaluation for the REACHOUT mental health support intervention, and examines the feasibility and perceived utility of PST. METHODS: Fifty-three adults with T1D were recruited to participate in a 6-hour, zoom-based PST program for mental health support. The program was structured in three parts: (1) internal motivation, resilience and empathy; (2) mindfulness, emotions and diabetes distress; and (3) active listening and deferring clinical questions to professionals. Candidates were evaluated based on eight pre-established competency criteria during a 5-day support trial with an assigned standardized T1D participant. Perceived usefulness of training skills was also assessed 3 months into the REACHOUT mental health support intervention. RESULTS: Fifty-one of the fifty-three candidates who completed training achieved the criteria to graduate. Mean scores for the eight competency domains were: listens actively (4.55); asks open-ended questions (4.12); expresses empathy (4.42); avoids passing judgment (4.67); sits with strong emotions (4.44); refrains from giving advice (4.38); makes reflections (4.5); and defers medical questions (4.58). Of the skills learned during the PST, 95% rated interpreting and discussing diabetes distress profile and expressing empathy as moderately to extremely useful. CONCLUSIONS: Findings demonstrate that it is feasible to recruit and graduate the number of trainees needed using a rigorous process. Only by making training protocols available can the PST be replicated and translated to other T1D populations (e.g. adolescents, parents of children with T1D).

Pulmonary Specialist-Supported Health Coaching Delivered by Lay Personnel Improves Receipt of Quality Care for Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial.

Purpose: Half of people living with chronic obstructive pulmonary disease (COPD) do not receive high-quality, evidenced-based care as described in international guidelines. We conducted secondary data analysis of a previously published study to assess the ability of a model of lay health coaching to improve provision of guideline-based care in a primary care setting. Methods: As part of a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive usual care or 9 months of health coaching from primary care personnel informed by a pulmonary specialist practitioner. Outcome measures included prescription of appropriate inhaler therapy, participation in COPD-related education, engagement with specialty care, prescription of smoking cessation medications, and patient ratings of the quality of care. Results: Baseline quality measures did not differ between study arms. At 9 months, coached patients were more likely (increase of 9.3% over usual care; P=0.014) to have received guideline-based inhalers compared to those in usual care. Coached patients were more likely to engage with pulmonary specialty care (increase of 8.3% over usual care with at least 1 visit; P=0.04) and educational classes (increase of 5.3% over usual care; P=0.03). Receipt of smoking cessation medications among patients smoking at baseline in the health coaching group increased 21.1 percentage points more than in usual care, a difference near statistical significance (P=0.06). Conclusions: Health coaching may improve the provision of quality chronic illness care for conditions such as COPD.

The status of person-centered contraceptive care in the United States: Results from a nationally representative sample.

CONTEXT: The Person-Centered Contraceptive Care measure (PCCC) evaluates patient experience of contraceptive counseling, a construct not represented within United States surveillance metrics of contraceptive care. We explore use of PCCC in a national probability sample and examine predictors of person-centered contraceptive care. METHODS: Among 2228 women from the 2017-2019 National Survey of Family Growth who reported receiving contraceptive care in the last year, we conducted univariate and multivariable linear regression to identify associations between individual characteristics and PCCC scores. RESULTS: PCCC scores were high ( x ¯ : 17.84, CI: 17.59-18.08 on a 4-20 scale), yet varied across characteristics. In adjusted analyses, Hispanic identity with Spanish language primacy and non-Hispanic other or multiple racial identities were significantly associated with lower average PCCC scores compared to those of non-Hispanic white identity (B = -1.232 [-1.970, -0.493]; B = -0.792 [-1.411, -0.173]). Gay, lesbian, or bisexual identity was associated with lower average PCCC scores compared to heterosexual (B = -0.673 [-1.243, -0.103]). PCCC scores had a positive association with incomes of 150%-299% and ≥300% of the federal poverty level compared to those of income <150% (150%-299%: B = 0.669 [0.198, 1.141]; ≥300%: B = 0.892 [0.412, 1.372]). Cannabis use in the past year was associated with lower PCCC scores (B = -0.542 [-0.971, -0.113]). CONCLUSIONS: The PCCC can capture differential experiences of contraceptive care to monitor patient experience and to motivate and track care quality over time. Differences in reported quality of care have implications for informing national priorities for contraceptive care improvements.

Community Health Center Staff Perspectives on Financial Payments for Social Care.

Policy Points State and federal payers are actively considering strategies to increase the adoption of social risk screening and interventions in health care settings, including through the use of financial incentives. Activities related to social care in Oregon community health centers (CHCs) provided a unique opportunity to explore whether and how fee-for-service payments for social risk screening and navigation influence CHC activities. CHC staff, clinicians, and administrative leaders were often unaware of existing financial payments for social risk screening and navigation services. As currently designed, fee-for-service payments are unlikely to strongly influence CHC social care practices. CONTEXT: A growing crop of national policies has emerged to encourage health care delivery systems to ask about and try to address patients' social risks, e.g., food, housing, and transportation insecurity, in care delivery contexts. In this study, we explored how community health center (CHC) staff perceive the current and potential influence of fee-for-service payments on clinical teams' engagement in these activities. METHODS: We interviewed 42 clinicians, frontline staff, and administrative leaders from 12 Oregon CHC clinical sites about their social care initiatives, including about the role of existing or anticipated financial payments intended to promote social risk screening and referrals to social services. Data were analyzed using both inductive and deductive thematic analysis approaches. FINDINGS: We grouped findings into three categories: participants' awareness of existing or anticipated financial incentives, uses for incentive dollars, and perceived impact of financial incentives on social care activities in clinical practices. Lack of awareness of existing incentives meant these incentives were not perceived to influence the behaviors of staff responsible for conducting screening and providing referrals. Current or anticipated meaningful uses for incentive dollars included paying for social care staff, providing social services, and supporting additional fundraising efforts. Frontline staff reported that the strongest motivator for clinic social care practices was the ability to provide responsive social services. Clinic leaders/managers noted that for financial incentives to substantively change CHC practices would require payments sizable enough to expand the social care workforce as well. CONCLUSIONS: Small fee-for-service payments to CHCs for social risk screening and navigation services are unlikely to markedly influence CHC social care practices. Refining the design of financial incentives-e.g., by increasing clinical teams' awareness of incentives, linking screening to well-funded social services, and changing incentive amounts to support social care staffing needs-may increase the uptake of social care practices in CHCs.

Pediatric ACEs and related life event screener (PEARLS) latent domains and child health in a safety-net primary care practice.

BACKGROUND: Research examining the connections between individual adverse childhood experiences (ACEs) and how groupings of interrelated adversities are linked with subsequent health is scarce, limiting our understanding of risk during a period of rapid expansion of ACE screening in clinical practice. The study objective was to conduct a psychometric analysis to derive latent domains of ACEs and related life events and assess the association between each domain and health outcome. METHODS: Participants (3 months-11 years) were recruited from the University of California San Francisco Benioff's Children Hospital Oakland Primary Care Clinic. Children were screened with the Pediatric ACEs and Related Life Events Screener (PEARLS) (n = 340), which assessed 17 total ACEs and related life events, including forms of abuse, household challenges, and social risks. Domains were constructed using confirmatory factor analysis and associations between the three identified domains and 14 health outcomes were assessed using multivariable linear and logistic regression models. RESULTS: Three PEARLS domains were identified: Maltreatment (ω = 0.73, ɑ=0.87), Household Challenges (ω = 0.70, ɑ=0.82), and Social Context (ω = 0.55, ɑ=0.70). Measurement invariance was supported across both gender and screening format. All domains were associated with poorer general and behavioral health and stomachaches. Maltreatment and Social Context were additionally associated with eczema while only Social Context was associated with increased odds of reporting headaches and somatic symptoms. CONCLUSION: In an underserved, urban west-coast pediatric population, the PEARLS found three adversity domains of Maltreatment, Household Challenges, and Social Context that all had an independent statistically significant association with poorer child health. The results provide a timely and more nuanced representation of risk that can inform clinical practice and policy using more targeted resources and interventions.

A Short-Form Measure of Diabetes Distress Among Adults With Type 1 Diabetes for Use in Clinical Practice: Development and Validation of the T1-DDS-7.

OBJECTIVE: Valid and reliable diabetes distress assessment is essential for identifying adults with elevated levels of concern and to guide targeted support. However, assessing diabetes distress must also be feasible in time-limited settings. We aimed to identify a short-form measure of the 28-item Type 1 Diabetes Distress Scale (T1-DDS-28) representing seven sources of type 1 diabetes distress that would be convenient for use in clinical practice. RESEARCH DESIGN AND METHODS: Based on the evaluation of influence and importance by 14 experts in diabetes care and research, we identified the best-performing item within each of seven sources of diabetes distress included in the T1-DDS-28. To further validate the proposed short-form measure, we used survey data from 2,016 adults living with type 1 diabetes. Validity was examined by exploratory factor analysis, Cronbach's α, test-retest reliability analysis, and correlations with other psychosocial measures. RESULTS: We identified a short-form measure of the T1-DDS-28 consisting of seven items, each representing a source of diabetes distress. These items showed satisfactory reliability (factor loadings > 0.45; α = 0.82; test-retest correlation, r = 0.90) and validity (correlation with T1-DDS-28, r = 0.95; area under the curve = 0.91; sensitivity 93%; specificity 89%) when combined in the short-form scale (T1-DDS-7). CONCLUSIONS: We propose the T1-DDS-7 as a valid and reliable measure for routine screening of diabetes distress among adults with type 1 diabetes. In case of elevated levels of diabetes distress, we recommend that a full-scale assessment and open dialogue follow the short-form measure before determining further treatment.

Household Social Needs, Emotional Functioning, and Stress in Low-Income Latinx Children and their Mothers.

Latinx families may be particularly vulnerable to emotional dysfunction, due to higher rates of economic hardship and complex social influences in this population. Little is known about the impact of environmental stressors such as unmet social needs and maternal stress on the emotional health of Latinx children from low-income families. We conducted secondary analyses using survey and biomarker data from 432 Latinx children and mothers collected in a separate study. We used binomial and multinomial logistic regression to test if household social needs, or maternal perceived stress or hair cortisol concentration (HCC), predicted child measures of emotional functioning or child HCC, independent of relevant sociodemographic factors. Approximately 40% of children in the sample had symptoms consistent with emotional dysfunction, and over 37% of households reported five or more social needs. High perceived maternal stress predicted higher odds of child emotional dysfunction (OR = 2.15; 95% CI [1.14, 4.04]; p = 0.01), and high maternal HCC was positively associated with high child HCC (OR = 10.60; 95% CI [4.20, 26.74]; p < 0.01). Most individual household social needs, as well as the level of household social need, were not independently associated with child emotional dysfunction or child HCC. Our findings begin to define a framework for understanding emotional health, stress, and resilience when caring for Latinx children and mothers living with high levels of social need, and the need for integrated mental health and social needs screening and interventions in settings that serve this population.

Unmet Social Needs and Patterns of Hair Cortisol Concentration in Mother-Child Dyads.

Background: Mothers and their children demonstrate dyadic synchrony of hypothalamic-pituitary-adrenal (HPA) axis function, likely influenced by shared genetic or environmental factors. Although evidence has shown that chronic stress exposure has physiologic consequences for individuals-including on the HPA axis-minimal research has explored how unmet social needs such as food and housing instability may be associated with chronic stress and HPA axis synchrony in mother-child dyads. Methods: We conducted a secondary analysis of data from 364 mother-child dyads with low-income recruited during a randomized trial conducted in an urban pediatric clinic. We used latent profile analysis (LPA) to identify subgroups based on naturally occurring patterns of within-dyad hair cortisol concentration (HCC). A logistic regression model predicted dyadic HCC profile membership as a function of summative count of survey-reported unmet social needs, controlling for demographic and health covariates. Results: LPA of HCC data from dyads revealed a 2-profile model as the best fit. Comparisons of log HCC for mothers and children in each profile group resulted in significantly "higher dyadic HCC" versus "lower dyadic HCC" profiles (median log HCC for mothers: 4.64 vs 1.58; children: 5.92 vs 2.79, respectively; P < .001). In the fully adjusted model, each one-unit increase in number of unmet social needs predicted significantly higher odds of membership in the higher dyadic HCC profile when compared to the lower dyadic HCC profile (odds ratio = 1.13; 95% confidence interval [1.04-1.23]; P = .01). Conclusion: Mother-child dyads experience synchronous patterns of physiologic stress, and an increasing number of unmet social needs is associated with a profile of higher dyadic HCC. Interventions aimed at decreasing family-level unmet social needs or maternal stress are, therefore, likely to affect pediatric stress and related health inequities; efforts to address pediatric stress similarly may affect maternal stress and related health inequities. Future research should explore the measures and methods needed to understand the impact of unmet social needs and stress on family dyads.

Association of Health-Related Social Needs With Quality and Utilization Outcomes in a Medicare Advantage Population With Diabetes.

Importance: Recent research highlights the association of social determinants of health with health outcomes of patients with type 2 diabetes (T2D). Objective: To examine associations between health-related social needs (HRSNs) and health care quality and utilization outcomes in a Medicare Advantage population with T2D. Design, Setting, and Participants: This cross-sectional study used medical and pharmacy claims data from 2019. An HRSN survey was given between October 16, 2019, and February 29, 2020, to Medicare Advantage beneficiaries. Inclusion criteria were diagnosis of T2D, age of 20 to 89 years, continuous Medicare Advantage enrollment in 2019, and response to the HRSN survey. Data were analyzed between June 2021 and January 2022. Exposures: Enrollment in Medicare Advantage, diagnosis of T2D, and completion of a survey on HRSNs. Main Outcomes and Measures: Quality outcomes included diabetes medication adherence, statin adherence, completion of a glycated hemoglobin (HbA1c) laboratory test in the past 12 months, and controlled HbA1c. Utilization outcomes included all-cause hospitalization, potentially avoidable hospitalization, emergency department discharge, and readmission. Results: Of the 21 528 Medicare Advantage beneficiaries with T2D included in the study (mean [SD] age, 71.0 [8.3] years; 55.4% women), most (56.9%) had at least 1 HRSN. Among the population with T2D reporting HRSNs, the most prevalent were financial strain (73.6%), food insecurity (47.5%), and poor housing quality (39.1%). In adjusted models, loneliness (odds ratio [OR], 0.85; 95% CI, 0.73-0.99), lack of transportation (OR, 0.80; 95% CI, 0.69-0.92), utility insecurity (OR, 0.86; 95% CI, 0.76-0.98), and housing insecurity (OR, 0.78; 95% CI, 0.67-0.91) were each associated with lower diabetes medication adherence. Loneliness and lack of transportation were associated with increased emergency visits (marginal effects of 173.0 [95% CI, 74.2-271.9] and 244.6 [95% CI, 150.4-338.9] emergency visits per 1000 beneficiaries for loneliness and transportation, respectively). Food insecurity was the HRSN most consistently associated with higher acute care utilization (marginal effects of 84.6 [95% CI, 19.8-149.4] emergency visits, 30.4 [95% CI, 9.5-51.3] inpatient encounters, and 17.1 [95% CI, 4.7-29.5] avoidable hospitalizations per 1000 beneficiaries). Conclusions and Relevance: In this cross-sectional study of Medicare Advantage beneficiaries with T2D, some HRSNs were associated with care quality and utilization. The results of the study may be used to direct interventions to the social needs most associated with T2D health outcomes and inform policy decisions at the insurance plan and community level.

Partner-developed electronic health record tools to facilitate social risk-informed care planning.

OBJECTIVE: Increased social risk data collection in health care settings presents new opportunities to apply this information to improve patient outcomes. Clinical decision support (CDS) tools can support these applications. We conducted a participatory engagement process to develop electronic health record (EHR)-based CDS tools to facilitate social risk-informed care plan adjustments in community health centers (CHCs). MATERIALS AND METHODS: We identified potential care plan adaptations through systematic reviews of hypertension and diabetes clinical guidelines. The results were used to inform an engagement process in which CHC staff and patients provided feedback on potential adjustments identified in the guideline reviews and on tool form and functions that could help CHC teams implement these suggested adjustments for patients with social risks. RESULTS: Partners universally prioritized tools for social risk screening and documentation. Additional high-priority content included adjusting medication costs and changing follow-up plans based on reported social risks. Most content recommendations reflected partners' interests in encouraging provider-patient dialogue about care plan adaptations specific to patients' social needs. Partners recommended CDS tool functions such as alerts and shortcuts to facilitate and efficiently document social risk-informed care plan adjustments. DISCUSSION AND CONCLUSION: CDS tools were designed to support CHC providers and staff to more consistently tailor care based on information about patients' social context and thereby enhance patients' ability to adhere to care plans. While such adjustments occur on an ad hoc basis in many care settings, these are among the first tools designed both to systematize and document these activities.

Biological Burden of Adverse Childhood Experiences in Children.

OBJECTIVE: This study aimed to examine relationships between adverse childhood experiences (ACEs) and related life events and allostatic load (AL)-"wear and tear" from chronic stress-in a pediatric population. METHODS: Children were screened with the PEdiatric ACEs and Related Life Event Screener (PEARLS) tool, a 17-item questionnaire capturing experiences of abuse, neglect, household challenges, and related life events. Biological data were available for 207 participants, and AL was operationalized using clinical or empirical cutoff points across 4 physiological systems (i.e., cardiac, metabolic, inflammatory, neurologic). Covariate-adjusted multivariable regression models were used to examine associations between AL with adversity and health. RESULTS: Children (mean age = 6.5 years, range = 1-11 years) had an average AL score of 1.9 (standard deviation = 1.7), and a U-shaped relationship was observed with child's age. Continuous PEARLS and original ACE scores were not associated with AL. However, children with a reported PEARLS score of 1 to 2 or original ACEs score of 1 to 3 had 1.5 (incidence rate ratio [IRR] = 1.50, 95% confidence interval [CI] = 1.09-2.08) and 1.4 (IRR = 1.41, 95% CI = 1.08-1.84) times greater AL, respectively, compared with participants with none reported. In secondary analyses, caregiver mental illness was associated with higher child AL (adjusted IRR = 1.27, 95% CI = 1.01-1.58). AL was also associated with poorer perceived child general health (adjusted ß = -0.87, 95% CI = -1.58 to -0.15) and greater odds of child obesity (adjusted odds ratio = 1.51, 95% CI = 1.23-1.89). CONCLUSIONS: Measuring AL in a pediatric population requires careful consideration of age. Higher AL was associated with a greater number of reported adversities and worse child health.

Social Needs and Acculturation as Predictors of Emotional Problems and Perceived Stress Among Latinx Mothers with Low Income.

Associations between household social needs, acculturation, and emotional health remain understudied, particularly among Latinx mothers. We analyzed baseline survey data from 455 Latinx mothers in a previous study. Using multinomial regression, we examined whether emotional problems and perceived stress were associated with household social needs and acculturation. Almost half the sample reported four or more household social needs. Social needs cumulatively and independently predicted increased odds of frequent emotional problems or perceived stress. Lower acculturation predicted lower odds of frequent emotional problems. There is increased risk for emotional problems and stress in low-income Latinx mothers who experience high social need. Integrated social service and mental health care models may be one way to improve health outcomes. More research is needed to understand how clinical settings can leverage unique cultural protective factors to address the social and emotional health needs of Latinx mothers.

Screening for adverse childhood experiences in pediatrics: A randomized trial of aggregate-level versus item-level response screening formats.

BACKGROUND: While there is growing support for screening for Adverse Childhood Experiences (ACEs), rigorous evidence on the efficacy and preference of screening methods is needed. OBJECTIVE: To examine caregiver: (1) rates of disclosure of their child's exposure to ACEs using item-level response (each item can be endorsed) versus aggregate-level response (only total score reported) screening format, (2) associations between family demographic factors and disclosure by screening format, and (3) emotional reaction and experience of screening formats in a diverse, low-income pediatric population. METHODS: Caregiver participants (n = 367) were randomized to complete the Pediatric ACEs and Related Life Events Screener (PEARLS) tool, in an aggregate-level response vs item-level response format from 2016-2019. Select caregivers (n = 182) participated in debriefing interviews. T-test and chi-square analyses in 2019 compared PEARLS disclosure rates and reactions between the screening modalities. Regression models explored interactions with child characteristics. Thematic analysis of interview notes captured caregiver screening experience. RESULTS: PEARLS disclosure rates were significantly higher in the aggregate-level response compared to the item-level response screening arm (p <0.05). This difference was accentuated for children identified as black and/or male (p <0.05). Caregiver reactions to PEARLS screening were rarely negative in either screening format. Qualitative data demonstrated strong caregiver preference for the item-level response format; additional themes include provider relationship, fear with disclosure, and screening outcome expectations. CONCLUSION: While caregivers reported a preference for the item-level response format, the aggregate-level response screening format elicited higher disclosures rates particularly for children who are black or ma. TRIAL REGISTRATION: Clinical trial registry: NCT04182906.