A cross-sectional study of relationships between social risks and prevalence and severity of pediatric chronic conditions.

BACKGROUND: To examine the differential relationships between seven social risk factors (individually and cumulatively) with the prevalence and severity of asthma, attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and overweight/obesity in children. METHODS: Using the 2017-2018 National Survey of Children's Health, we examined associations between social risk factors (caregiver education, caregiver underemployment, discrimination, food insecurity, insurance coverage, neighborhood support, and neighborhood safety) and the prevalence and severity of asthma, ADHD, ASD, and overweight/obesity. We used multivariable logistic regression to assess the relationship between individual and cumulative risk factors with each pediatric chronic condition, controlling for child sex and age. RESULTS: Although each social risk factor was significantly associated with increased prevalence and/or severity of at least one of the pediatric chronic conditions we investigated, food insecurity was significantly associated with higher disease prevalence and severity for all four conditions. Caregiver underemployment, low social support, and discrimination were significantly associated with higher disease prevalence across all conditions. For each additional social risk factor a child was exposed to, their odds of having each condition increased: overweight/obesity (aOR: 1.2, 95% CI: [1.2, 1.3]), asthma (aOR: 1.3, 95% CI: [1.2, 1.3], ADHD (aOR: 1.2, 95% CI: [1.2, 1.3]), and ASD (aOR: 1.4, 95% CI: [1.3, 1.5]). CONCLUSIONS: This study elucidates differential relationships between several social risk factors and the prevalence and severity of common pediatric chronic conditions. While more research is needed, our results suggest that social risks, particularly food insecurity, are potential factors in the development of pediatric chronic conditions.

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

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

A Qualitative Study of Maternal Perceptions of Stress and Parenting During Early Childhood.

OBJECTIVE: Exposure to maternal stress in early childhood can increase risk for learning and behavior challenges. We sought to gain in-depth understanding of how mothers perceive stressors to impact child wellbeing and identify mothers' strategies for navigating stressors with their young children. METHODS: We recruited English- and Spanish-speaking mothers from a primary care clinic serving predominantly publicly insured children. Twenty-one mothers (aged >18 years) of children (aged 6-29 months) participated in in-depth, semi-structured interviews to discuss their experiences and beliefs regarding stress and parenting. Interviews were recorded, transcribed verbatim, and analyzed using the constant comparative method associated with a grounded theory approach. RESULTS: We developed the following hypothesized explanatory model based on our key thematic findings: Mothers described a dyadic model of stress, whereby both their children's and their own experiences of and responses to stressors are interdependent. Mothers use preventive and responsive buffering to mitigate the impact of stress on their children; however, their access to resources, including social and financial support, shapes their capacity for implementing such strategies. Affection and other forms of relational support may function to protect against the negative impacts of stress. CONCLUSION: In the setting of poverty-related chronic stressors, mothers play an active role in mitigating the impact of stress on their children's wellbeing through responsive caregiving. Policies aimed at reducing poverty-related stress exposures and experiences among low-income families may be key interventions for promoting responsive caregiving during a critical time in child development.

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

BACKGROUND: Growing evidence linking social determinants of health (SDOH) to child health outcomes has prompted widespread recommendations for pediatricians to screen and refer for adverse SDOH at primary care visits. Yet there is little evidence to date demonstrating the effectiveness of practice-based SDOH screening and referral interventions on increasing family engagement with resources. This hybrid type 2 effectiveness-implementation trial aims to demonstrate the non-inferiority of a low-touch implementation strategy in order to facilitate dissemination of an existing SDOH screening and referral system (WE CARE) and demonstrate its effectiveness and sustainability in various pediatric practices. METHODS: We recruited eighteen pediatric practices in fourteen US states through two pediatric practice-based research networks. For this stepped wedge cluster RCT, practices serve as their own controls during the Usual Care phase and implement WE CARE during the intervention phase via one of two randomized implementation strategies: self-directed, pre-recorded webinar vs. study team-facilitated, live webinar. We collect data at practice, clinician/staff, and parent levels to assess outcomes grounded in the Proctor Conceptual Model of Implementation Research. We use generalized mixed effects models and differences in proportions to compare rates of resource referrals by implementation strategy, and intention-to-treat analysis to compare odds of engagement with new resources among families enrolled in the Usual Care vs. WE CARE phases. DISCUSSION: Findings from this trial may inform decisions about broader dissemination of SDOH screening systems into a diverse spectrum of pediatric practices across the US and potentially minimize the impact of adverse SDOH on children and families.

A Social Care System Implemented in Pediatric Primary Care: A Cluster RCT.

OBJECTIVES: To assess the implementation and effectiveness of the augmented WE CARE social care system on low-income children's health care utilization and child maltreatment outcomes. METHODS: We conducted a type 1 hybrid effectiveness-implementation cluster randomized controlled trial at 6 community health centers. Full-term infants were followed from birth to age 3. The 3 experimental clinics implemented the augmented WE CARE system at well-child visits, consisting of a self-report screening instrument for 7 basic needs; an electronic health record-generated resource information referral system; and access to a peer patient navigator. Families at control community health centers received usual care; 1 control site was contaminated and removed from primary analysis. We analyzed results using generalized mixed-effects models. RESULTS: Overall, 878 children were followed until age 3. Implementation of WE CARE was poor with only 28.9% of visits having a WE CARE screener documented. WE CARE families received significantly more resource referrals than control families (43.1% vs 1.9%, adjusted odds ratio 4.6; 95% confidence interval, 2.0-5.6); 20% were referred to the patient navigator. WE CARE children had significantly higher immunization adherence ratios. Although there were no statistically significant differences with well-child visits, WE CARE children had higher rates of emergency department visits than control children. By age 3, WE CARE children had significantly higher hospitalization rates (14.1% vs 10.4%, adjusted odds ratio 1.3, 95% confidence interval: 1.03-1.7). There were no statistically significant differences with maltreatment outcomes. CONCLUSIONS: We found poor implementation and mixed benefits for the augmented WE CARE system on immunization, health care utilization, and maltreatment outcomes in early childhood.

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

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

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

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

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

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