Trends in the Use and Discussion of Race in Pediatrics Articles Over 75 Years.

BACKGROUND AND OBJECTIVES: Race-based medicine, which falsely assumes that race is biological, is common in the published medical literature. We analyzed trends in the use of race in Pediatrics articles over a 75-year period. METHODS: We analyzed a random sample of 50 original research articles published each decade in Pediatrics from 1948 to 2022. RESULTS: Of 375 articles, 39% (n = 147) included race. Among articles, 85% (n = 116) used race only to describe study subjects, 7% (n = 9) described race as a social construct, and 11% (n = 15) described race as a biological construct. Only 7% (n = 10) of studies provided a reason for including race. Statements reflective of racial bias or discrimination were identified in 22% (n = 30) of the articles that mentioned race. Although statements concerning for explicit racial bias were uncommon, with none identified in the most recent decade, statements suggestive of implicit racial bias still occurred (22%, 5 of 23). Race was presented as a dichotomy, such as "white/nonwhite," in 9% of studies (n = 12). Regarding currently nonrecommended terminology, the term "minorities" was used in 13% of studies (n = 18); 25% of studies used the term "others" (n = 34), and among these, 91% (n = 31 of 34) did not provide any definition, an occurrence that increased over time at a rate of 0.9%/year. CONCLUSIONS: Although there has been improvement over the past 75 years in the reporting of race in published studies in Pediatrics, significant opportunities for further improvement remain.

WIC staff and healthcare professional perceptions of an EHR intervention to facilitate referrals to and improve communication and coordination with WIC: A qualitative study.

Objectives: Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has numerous benefits, yet many eligible children remain unenrolled. This qualitative study sought to explore perceptions of a novel electronic health record (EHR) intervention to facilitate referrals to WIC and improve communication/coordination between WIC staff and healthcare professionals. Methods: WIC staff in three counties were provided EHR access and recruited to participate. An automated, EHR-embedded WIC participation screening and referral tool was implemented within 8 healthcare clinics; healthcare professionals within these clinics were eligible to participate. The interview guide was developed using the Consolidated Framework for Implementation Research to elicit perceptions of this novel EHR-based intervention. Semi-structured interviews were conducted via telephone. Interviews were recorded, transcribed, coded, and analyzed using thematic analysis. Results: Twenty semi-structured interviews were conducted with eight WIC staff, seven pediatricians, four medical assistants, and one registered nurse. Most participants self-identified as female (95%) and White (55%). We identified four primary themes: (1) healthcare professionals had a positive view of WIC but communication and coordination between WIC and healthcare professionals was limited prior to WIC having EHR access; (2) healthcare professionals favored WIC screening using the EHR but workflow challenges existed; (3) EHR connections between WIC and the healthcare system can streamline referrals to and enrollment in WIC; and (4) WIC staff and healthcare professionals recommended that WIC have EHR access. Conclusions: A novel EHR-based intervention has potential to facilitate healthcare referrals to WIC and improve communication/coordination between WIC and healthcare systems.

Reducing Intergenerational Poverty-An Essential Driver of Health.

This Viewpoint discusses a report from the National Academies of Science, Engineering, and Medicine on how to address intergenerational poverty.

Diversity, Equity, and Inclusion, Child Health, and the Pediatric Subspecialty Workforce.

Using multiple metrics, the diversity of the pediatric population in the United States is increasing. However, recent data suggest significant disparities in both the prevalence and management of child health conditions cared for by pediatric subspecialists. These inequities occur across multiple dimensions of diversity, including race and ethnicity, country of origin, socioeconomic status, sex and gender, and disability. Research also suggests that attending to diversity, equity, and inclusion in the medical workforce may positively affect health outcomes. High-quality pediatric subspecialty care thus requires knowledge of these data, attention to the effects of social drivers, including racism and discrimination, on health and wellbeing, and interventions to improve pediatric health equity through educational, practice, policy, and research innovations. In this article, we review data on the diversity of the pediatric population and pediatric subspecialty workforce, suggest potential strengths, weaknesses, opportunities, and threats of current diversity, equity, and inclusion initiatives in academic pediatrics, and provide recommendations across 4 domains: education and training, practice, policy, and future research. The ultimate goal of pediatrics is to improve health equity for all infants, children, adolescents, and young adults cared for in the United States by pediatric subspecialists.

Examining Full-Time Academic General Pediatric Faculty Compensation by Gender, Race, and Ethnicity: 2020-2021.

OBJECTIVE: In medicine, women have lower lifetime earnings than men. To our knowledge, an in-depth examination of academic general pediatric faculty compensation by gender, race, and ethnicity has not been conducted. We aimed to 1) explore full-time academic general pediatric faculty salary differences by race and ethnicity; 2) explore these differences among all full-time pediatric faculty. METHODS: We performed a cross-sectional study using data on median full-time academic general pediatric faculty compensation for the academic year of 2020-2021 from the Association of American Medical Colleges Medical School Faculty Salary Survey report. Pearson's chi-square tests were used to evaluate the association of faculty rank with gender, race, ethnicity, and degree. We used hierarchical generalize linear models with a log link and a gamma distribution to model to assess the association of median salary with faculty race and ethnicity, adjusting for degree, rank, and gender. RESULTS: Men academic general pediatric faculty consistently had higher median salaries than women faculty even after adjusting for degree, rank, race, and ethnicity. Underrepresented in medicine academic general pediatric faculty had a lower median salary when compared to White faculty, and this was similar when adjusted for degree, rank, race, and ethnicity. CONCLUSIONS: Our results demonstrated broad disparities in general academic pediatric compensation by both gender and race and ethnicity. Academic medical centers must identify, acknowledge, and address inequities in compensation models.

Incorporating Health Policy and Advocacy Curricula Into Undergraduate Medical Education in the United States.

Physicians serve as crucial advocates for their patients. Undergraduate medical education (UME) must move beyond the biomedical model, built upon the perception that health is defined purely in the absence of illness, to also incorporate population health through health policy, advocacy, and community engagement to account for structural and social determinants of health. Currently, the US guidelines for UME lack structured training in health policy or advocacy, leaving trainees ill-equipped to assume their role as physician-advocates or to engage with communities. There is an undeniable need to educate future physicians on legislative advocacy toward improving the social determinants of health through the creation of evidence-based health policy, in addition to training in effective techniques to engage in partnership with the communities in which physicians serve. The authors of this article also present curricular case studies around two programs at their institution that could be used to implement similar programs at other US medical schools.

North Carolina's Medicaid Transformation: the Early Enrollee Experience.

INTRODUCTION: On July 1, 2021, North Carolina's Medicaid Transformation mandatorily switched 1.6 million Medicaid beneficiaries from fee-for-service to managed care plans. We examined the early enrollee experience in terms of engagement in plan selection, provider continuity, use of primary care visits, and assistance with social needs. METHODS: Using electronic health records (EHR) covering pre- and post-transition periods (1/1/2019-5/31/2022) from the largest provider network in western North Carolina, we identified all children and adults under age 65 with continuous Medicaid or private coverage. We conducted primary surveys of a random sample of Medicaid-covered enrollees and obtained self-reported rates of engagement in plan selection, continuity of provider access, and receipt of social need assistance. We used comparative interrupted time series models to estimate the relative change in primary care visits associated with the transition. RESULTS: Our EHR-based study cohorts included 4859 Medicaid and 5137 privately insured enrollees, with 398 Medicaid enrollees in the primary surveys. We found that 77.3% of survey participants reported that the managed care plan they were on was not chosen but automatically assigned to them, 13.1% reported insufficient information about the transition, and 19.2% reported lacking assistance with plan choice. We found that 5.9% were assigned to a different primary care provider. Over 29% reported not receiving any additional social need assistance. The transition was associated with a 7.1% reduction (95% CI, -11.5 to -2.7%) in the volume of primary care visits among Medicaid enrollees relative to privately insured enrollees. CONCLUSIONS: Medicaid enrollees in North Carolina may have had limited awareness and engagement in the transition process and experienced a reduction in primary care visits. As the state's transition process gains a foothold, future policy needs to improve enrollee engagement and develop evidence on healthcare utilization and patient outcomes.

Assessing and Improving WIC Enrollment in the Primary Care Setting: A Quality Initiative.

BACKGROUND AND OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides food and other resources to mitigate the harmful effects of food insecurity on child and maternal health. From a 2009 peak, nationwide WIC participation declined through 2020. Our objectives were to understand factors influencing WIC engagement and improve WIC enrollment through novel, primary care-based quality improvement interventions. METHODS: Plan-do-study-act cycles were implemented at a majority Medicaid-insured pediatric primary care clinic. Universal WIC screening at <5-year-old well-child visits was initiated, with counseling and referrals offered to nonparticipants. Clinic providers received WIC education. WIC screening, counseling reminders, and referrals were streamlined via the electronic health record. Families were surveyed on WIC participation barriers. Patient demographic data were analyzed for predictors of WIC participation. RESULTS: Mean new WIC enrollments increased significantly (42%) compared with baseline, with sustained special cause variation after study interventions. Provider WIC knowledge improved significantly at study end (P <.001). Rates of WIC screening, counseling, and referrals remained stable for >1 year after study interventions. The most common family-reported barriers to WIC participation were "Access problems" and "WIC knowledge gap." Factors associated with decreased WIC participation in multivariable analysis were increasing age (P <.001), and non-Medicaid insurance status (P = .03). CONCLUSIONS: We demonstrate feasible primary care-based screening, education, and referral interventions that appear to improve WIC enrollment. We identify knowledge gap and access problems as major potentially modifiable barriers to WIC participation. The expansion of similar low-cost interventions into other settings has the potential to benefit under-resourced children and families.

Early Specialization in Medical Education-A Pathway to Mitigate the Growing Physician Deficit.

This Viewpoint discusses proposed pathways of modifying the medical education timeline that would aid in producing US physicians in a timelier manner.

Exploring Perceptions of a Fresh Food Prescription Program during COVID-19.

This qualitative study aimed to elicit the perspectives of individuals with food insecurity (FI) who were enrolled in a Fresh Food Prescription (FFRx) delivery program through a collaboration between an academic medical center and multiple community partners in the southeastern United States. Semi-structured interviews and open-ended survey responses explored the experiences of participants enrolled in a FFRx delivery program during the COVID-19 pandemic. The interviews probed the shopping habits, food security, experience, and impact of the program on nutrition, health, and well-being; the surveys explored the perceptions of and satisfaction with the program. A coding scheme was developed inductively, and a thematic analysis was conducted on raw narrative data using Atlas.ti 8.4 to sort and manage the data. The themes included that the program promoted healthy dietary habits, improved access to high-quality foods, improved well-being, enhanced financial well-being, and alleviated logistical barriers to accessing food and cooking. Participants provided suggestions for FFRx improvement. Future studies may facilitate improved clinical-community partnerships to address FI.

Trends in the Diversity of Pediatric Faculty: 2000 to 2020.

OBJECTIVE: Academic medicine diversity is important for addressing health disparities and training the next generation. A recent study highlighted the lack of diversity among pediatric trainees over time. However, trends in US pediatric faculty diversity have not been clearly illuminated. The aim of this study is to evaluate pediatric faculty diversity trends and compare racial/ethnic representation between pediatric faculty and the US population. METHODS: Repeat cross-sectional study of the Association of American Medical Colleges Faculty Roster of pediatric faculty from 2000 to 2020. Trends in sex, race, ethnicity, and rank were compared with the Cochran-Armitage test. Data on faculty race/ethnicity were compared with the general and child population by using US Census Bureau data. RESULTS: Trends in underrepresented in medicine (URiM) faculty representation significantly increased at all ranks: professor (+3.5%, P < .0001), associate professor (+3.0%, P = .0001), and assistant professor (+2.5%, P = .0001). URiM male representation remained unchanged (P = .14), whereas significantly increased trends occurred in URiM female representation (+3.4%, P < .0001). African American/Black males significantly decreased representation at associate (-0.4%, P = .04) and assistant professor levels (-0.6%, P < .0001), and American Indian/Alaska Native males significantly decreased representation at the assistant professor rank (-0.1%, P < .0001). The percentage of URiM pediatric faculty representation was considerably lower compared with 2020 US overall and longitudinal child population representation. CONCLUSION: The stagnation of URiM male representation and lack of faculty diversity reflective of the US population may have a critical impact on the ability to recruit/retain a diverse pediatric workforce and promote equitable care.

Qualitative Perceptions of an Anticipated Fresh Food Prescription Program.

Objective: Food insecurity (FI) is a growing public health problem. Produce prescriptions are known to improve healthy eating and decrease FI; however, few studies have incorporated community voice prior to its implementation. In this study, we aimed to elicit perspectives of individuals at risk for FI and the potential impact of a fresh food prescription (FFRx) program. Methods: We conducted this qualitative descriptive study through an academic medical center in collaboration with community partners. We conducted focus groups involving Latinx (N = 16) and African-American (N = 8) adults in community settings. Data were interpreted using an inductive thematic analysis. Results: Three overarching themes emerged: (1) fresh food accessibility was limited by cost, household size, and transportation but enhanced by food pantries, budgeting, and education; (2) cooking behaviors were curbed by time constraints and unfamiliarity but propagated by passion, traditions, and communal practices; and (3) health and wellness deterrents included unhealthy diets driven by cultural and familial norms; however, weight loss and awareness of comorbidities were positive motivators. Participants shared their preference for local produce and cooking classes as components of a FFRx program while raising concerns about low participation due to the stigma of receiving aid. Conclusions: Our findings illuminated interest in engaging in a FFRx program and learning ways to prepare healthy foods. A program distributing fresh produce and healthy lifestyle education could close gaps identified in African-American and Latinx communities at risk for FI.

Strategies and Lessons Learned from a Home Delivery Food Prescription Program for Older Adults.

Food insecurity (FI) is a growing health problem, worsening during the COVID-19 pandemic. Fresh food prescription programs (FFRx) have been shown to increase healthy eating and decrease FI, but few FFRx are community-informed, or theory based. Our FFRx was a delivery program developed to alleviate FI for older adults. It was implemented in an academic medical center and guided by the Capabilities, Opportunities, Motivations, and Behaviors and Theoretical Domains Framework. We tested impacts of the program on FI, Fruit and Vegetable (FV) intake, depression, and loneliness at six-month intervals. During the FFRx, 31 people completed surveys every six months. FI decreased by an average of 2.03 points (p = <.001) while FV intake increased from a mean of 2.8 servings per day to 2.9 servings per day (p = .53). Depression and loneliness scores stayed stable. Preliminary data from this FFRx program, a partnership between an academic medical center and community partners, had positive impacts on FI.

Social Risk Factors Influence Pediatric Emergency Department Utilization and Hospitalizations.

OBJECTIVE: To characterize the association of children's social risk factors with total number of emergency department (ED) visits or hospitalization and time to first subsequent ED or hospitalization. STUDY DESIGN: This was a retrospective cohort study of patients seen at a general pediatric clinic between 2017 and 2021 with documented ≥1 social risk factors screened per visit. Negative binomial or Poisson regression modeled ED utilization and hospitalizations as functions of the total number of risk factors or each unique risk factor. Time-varying Cox models were used to evaluate differences between those who screened positive and those who screened negative, controlling for demographic and clinical covariates. RESULTS: Overall, 4674 patients (mean age, 6.6 years; 49% female; 64% Hispanic; 21% Black) were evaluated across a total of 20 927 visits. Children with risk factors had higher rates of attention-deficit hyperactivity disorder, failure to gain weight, asthma, and prematurity compared with children with no risk (all P < .01). Adjusted models show a positive association between increased total number of factors and ED utilization (incidence rate ratio [IRR], 1.18; 95% CI, 1.12-1.23) and hospitalizations (IRR, 1.36; 95% CI, 1.26-1.47). There were no associations between a positive screen and time to first ED visit (hazard ratio [HR], 0.95; 95% CI, 0.85-1.06; P = .36) or hospitalization (HR, 1.15; 95% CI, 0.84-1.59; P = .40). CONCLUSIONS: Social risk factors were associated with increased ED utilization and hospitalizations at the patient level but were not significantly associated with time to subsequent acute care use. Future research should evaluate the effect of focused interventions on health care utilization, such as those addressing food insecurity and transportation challenges.

Association of Food Insecurity with Mental Health Outcomes in Parents and Children.

BACKGROUND: Food insecurity affects 13.7 million US households and is linked to poor mental health. Families shield children from food insecurity by sacrificing their nutritional needs, suggesting parents and children experience food insecurity differentially. OBJECTIVE: To identify the associations of food insecurity and mental health outcomes in parents and children DATA SOURCES: PubMed, Embase, Web of Science, and PsycInfo STUDY ELIGIBILITY CRITERIA: We included original research published in English from January 1990 to June 2020 that examined associations between food insecurity and mental health in children or parents/guardians in the United States. STUDY APPRAISAL AND SYNTHESIS METHODS: Two reviewers screened studies for inclusion. Data extraction was completed by one reviewer and checked by a second. Bias and confounding were assessed using the Agency for Healthcare Research and Quality RTI Item Bank. Studies were synthesized qualitatively, grouped by mental health outcome, and patterns were assessed. Meta-analyses were not performed due to high variability between studies. RESULTS: We included 108 studies, assessing 250,553 parents and 203,822 children in total. Most studies showed a significant association between food insecurity and parental depression, anxiety, and stress, and between food insecurity and child depression, externalizing/internalizing behaviors, and hyperactivity. LIMITATIONS: Most studies were cross-sectional and many were medium- or high-risk for bias or confounding. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Food insecurity is significantly associated with various mental health outcomes in both parents and children. The rising prevalence of food insecurity and mental health problems make it imperative that effective public health and policy interventions address both problems.