Highlights • 94% of top-ranked US universities have ≥1 prematriculation immunization requirement. • Universities often require more immunizations than the jurisdictional law. • Philosophical ...exemptions to requirements are disallowed at 46% of universities. • 67% of US jurisdictions require one or more university level immunization requirement.
Children in families facing energy insecurity have greater odds of poor health and developmental problems. In this study of families who requested and received medical certification for utility ...shut-off protection and were contacted by our Medical Legal Partnership (MLP), we aimed to assess concurrent health-related social needs related to utilities, housing, finances, and nutrition.
After medical certificates were completed at our academic pediatric center, our MLP office contacted families and assessed utility concerns as well as other health, social, and legal needs. In this observational study, we present descriptive analyses of patients who received certificates from September 2019 to May 2020 via data collected through the MLP survey during the coronavirus disease 2019 pandemic (June 2020-December 2021).
Of 167 families who received utility shut-off protection from September 2019 to May 2020, 84 (50.3%) parents and guardians were successfully contacted. Most (93%) found the medical certificate helpful. Additionally, 68% had applied for Energy Assistance, and 69% reported they were on utility company payment plans. Most (78%) owed arrearages, ranging from under $500 to over $20 000, for gas, electric, and/or water bills. Food, housing, and financial insecurity screening positivity rates were 65%, 85%, and 74%, respectively.
Patients who were contacted by an MLP after receiving medical certification for utility shutoff protection were found to have challenges paying for utilities and faced multiple food, housing, and financial stressors. Through consultation and completion of medical forms for utility shutoff protection, pediatricians and MLPs can provide resources and advocacy to support families' physical, emotional, and psychosocial needs.
Early identification of autism spectrum disorder (ASD) is associated with improved cognitive and behavioral outcomes. Targeted strategies are needed to support equitable access to diagnostic services ...to ensure that children from low-income and racial/ethnic minority families receive the benefits of early ASD identification and treatment.
To test the efficacy of family navigation (FN), an individually tailored, culturally informed care management strategy, to increase the likelihood of achieving diagnostic ascertainment among young children at risk for ASD.
This randomized clinical trial of 249 families of children aged 15 to 27 months who had positive screening results for possible ASD was conducted in 11 urban primary care sites in 3 cities. Data collection occurred from February 24, 2015, through November 5, 2018. Statistical analysis was performed on an intent-to-treat basis from November 5, 2018, to July 27, 2020.
Families were randomized to FN or conventional care management (CCM). Families receiving FN were assigned a navigator who conducted community-based outreach to families to address structural barriers to care and support engagement in recommended services. Families receiving CCM were assigned to a care manager, who did limited telephone outreach. Families received FN or CCM after positive initial screening results and for 100 days after diagnostic ascertainment.
The primary outcome, diagnostic ascertainment, was measured as the number of days from randomization to completion of the child's clinical developmental evaluation, when a diagnosis of ASD or other developmental disorder was determined.
Among 250 families randomized, 249 were included in the primary analysis (174 boys 69.9%; mean SD age, 22.0 3.5 months; 205 82.3% publicly insured; 233 93.6% non-White). Children who received FN had a greater likelihood of reaching diagnostic ascertainment over the course of 1 year (FN, 108 of 126 85.7%; CCM, 94 of 123 76.4%; unadjusted hazard ratio HR, 1.39 95% CI, 1.05-1.84). Site (Boston, New Haven, and Philadelphia) and ethnicity (Hispanic vs non-Hispanic) moderated the effect of FN (treatment × site interaction; P = .03; Boston: HR, 2.07 95% CI, 1.31-3.26; New Haven: HR, 1.91 95% CI, 0.94-3.89; and Philadelphia: HR, 0.91 95% CI, 0.60-1.37) (treatment × ethnicity interaction; P < .001; Hispanic families: HR, 2.81 95% CI, 2.23-3.54 vs non-Hispanic families: HR, 1.49 95% CI, 1.45-1.53). The magnitude of FN's effect was significantly greater among Hispanic families than among non-Hispanic families (diagnostic ascertainment among Hispanic families: FN, 90.9% 30 of 33, and CCM, 53.3% 16 of 30; vs non-Hispanic families: FN, 89.7% 35 of 39, and CCM, 77.5% 31 of 40).
Family navigation improved the likelihood of diagnostic ascertainment among children from racial/ethnic minority, low-income families who were detected as at risk for ASD in primary care. Results suggest differential effects of FN by site and ethnicity.
ClinicalTrials.gov Identifier: NCT02359084.
Medical-Legal Partnerships (MLPs) integrate medical and legal care to address prevalent health-harming legal needs (HHLN) among socioeconomically marginalized populations. MLPs address a diverse ...array of social determinants of health (SDOH) and have been shown to positively impact children's health. Less is known, however, about how MLPs affect health care providers. MLPs may affect child health by changing clinical practice and provider behavior, and transforming providers' relationships with their patients and patients' families. Examining and understanding how MLPs affect providers is thus critical to elucidating how MLPs may ultimately impact child health.
We examined one pediatric MLP at an academic medical center in New Haven, Connecticut. We conducted semi-structured interviews with 20 pediatric providers who had engaged with the MLP and 20 parents/guardians who had interacted with the MLP. We analyzed the qualitative data using inductive coding, primarily drawing upon provider interviews.
The MLP affected providers in five major ways. The MLP 1) improved provider awareness of SDOH and HHLN, 2) expanded provider perceptions of their role and responsibilities as clinicians, 3) improved provider efficacy in addressing SDOH and HHLN, 4) empowered providers to engage in systemic advocacy, and 5) improved providers' relationships with patients' families.
Our study identifies multiple ways that a pediatric MLP affects providers. Our findings suggest that MLPs can improve patient and population health by equipping providers with the knowledge and tools needed to assist patients with HHLN and SDOH, improving provider-family relationships, and encouraging providers to engage in systemic and institutional advocacy.
Abstract
Psychoeducation, where clinicians teach problem-solving skills in a supportive environment, can help address families’ social vulnerabilities and promote well-being. Group well-child care ...(GWCC) may provide unique opportunities for pediatric residents to improve their skills in psychoeducation. Our aim was to characterize pediatric residents’ perspectives and experiences of communication while conducting both individual well-child care and GWCC. We used a longitudinal qualitative study design to conduct 15 semistructured interviews with five pediatric residents who facilitated GWCC. Using the constant comparative method, we characterized pediatric residents’ perspectives and experiences of communication while conducting both individual well-child care and GWCC. Four themes emerged. Residents perceived that GWCC (i) enabled families to honestly share their knowledge and parenting practices, (ii) allowed time and a space for families to share personal stories and scenarios, (iii) facilitated discussions of maternal health and psychosocial matters, toward which residents felt ambivalence, and (iv) fostered skills in psychoeducation that transferred to the rest of their clinical practice. When pediatric residents lead GWCC, they perceive that they can facilitate key aspects of psychoeducation, enabling them to assist families in meeting complex social needs. Residents describe that they transfer psychoeducation skills learned in GWCC to the rest of their practice.
Parents of children with autism spectrum disorder (ASD) show increased levels of parenting stress, but only one study has examined this association before a diagnostic evaluation. We conducted a ...cross-sectional study of parenting stress in 317 low SES parents with children at-risk for ASD before a diagnostic evaluation. Multiple regression modeling evaluated the associations between parenting stress and parent and child factors. Parenting stress was negatively associated with social support and positively associated with active avoidance coping and parental worry. However, parenting stress was not associated with the child’s ASD symptom severity or adaptive functioning, except for self-direction. Findings suggest parenting stress among parents of children at risk of ASD should be assessed prior to diagnosis.
Well-child care has suboptimal outcomes regarding adherence to appointments and recall of guidance, especially among families facing structural barriers to health. Group well-child care (GWCC) aims ...to improve these outcomes by enhancing anticipatory guidance discussions and peer education. We conducted a randomized controlled trial, comparing GWCC with traditional, individual well-child care (IWCC) and assessed health care utilization, immunization timeliness, recall of anticipatory guidance, and family-centered care. Ninety-seven mother-infant dyads were randomized to GWCC or IWCC. Compared with IWCC infants, GWCC infants attended more of the 6 preventive health visits (5.41 vs 4.87, P < .05) and received more timely immunization at 6 months and 1 year but did not differ in emergency or hospital admission rates. There were no differences in mothers’ reports of anticipatory guidance received or family-centered care. As primary care is redesigned for value-based care and structural vulnerabilities are considered, GWCC may be a key option to consider.
To evaluate the Healthy Eating through Group Well-Child Care (GWCC) intervention, a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and primary care partnership which ...seeks to promote responsive feeding practices among low-income caregivers, by examining its impact on infant growth and exploring the experiences of caregivers who participated in this intervention.
Using a difference-in-differences approach, we examined change in weight-for-length among infants in GWCC before versus after implementation of the intervention compared with infants in individual well-child care (IWCC) over the same time-period. In parallel, we conducted semi-structured interviews in English and Spanish with caregivers who participated in the intervention to explore their perspectives and analyzed transcripts via the constant comparative method to identify salient themes.
Using electronic health record data from 279 GWCC and 6134 IWCC participants, we found no significant difference in first-year weight-for-length trajectory associated with participation in the intervention. We reached thematic saturation after 19 interviews with 22 caregivers and identified four major themes around feeding: 1) structural barriers limit access to healthy foods through WIC, 2) conflicting sources of nutrition advice challenge parental decision making, 3) exposure to novel foods facilitated further experimentation with healthier foods, and 4) discussion of responsive feeding facilitated awareness and adoption.
A primary care and WIC partnership to promote responsive feeding in the context of GWCC was well received by caregivers but was not associated with improved weight-for-length among infants. Structural barriers to implementing responsive feeding and healthy eating practices may have impacted lack of measurable results from the intervention.
Asthma health disparities are widely recognized, with worse outcomes in children from low income families. In a Medical-Legal Partnership (MLP), an attorney is embedded in a healthcare setting to ...address social determinants of health. We studied whether an MLP could impact asthma exacerbation rates in a vulnerable urban population at an academic children's hospital.
The study population comprised children with asthma who were referred to the MLP between 2013 and 2017. We compared healthcare utilization for asthma exacerbations managed in primary care, emergency department and inpatient settings in the year before and year after MLP intervention.
98 children with asthma were included in the study. The mean total encounters per person per year decreased from 1.16 to 0.66 (relative reduction 44.2%, p < 0.01). The largest effect was on hospitalizations, with a reduction from 0.33 to 0.10 hospitalizations per patient per year (relative reduction 69.7%, p < 0.01). Encounters for asthma exacerbations in the primary care office and emergency department also decreased but these changes did not meet statistical significance.
In a pediatric population with asthma, an MLP intervention was associated with a significant reduction in asthma exacerbation encounters and hospitalizations comparing the year before and after MLP intervention. Further studies are needed to better understand which interventions are most effective, and for which patient groups MLP referral would be particularly useful. MLPs may be an important way to reduce health disparities in patients with asthma and other chronic illnesses.
Management/control; pediatrics
Families, pediatric providers, and service systems would benefit from expanded knowledge regarding (1) who is most likely to receive a recommended diagnostic evaluation after a positive primary ...care-administered autism screen and (2) of those who screen positive, who is most likely to be diagnosed with autism?
Participants included 309 predominantly low-income, racial/ethnic minority parents and their child, aged 15 to 27 months, who screened positive on the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F). Generalized estimating equations were used to fit models of predictors for each binary outcome: receiving a diagnostic evaluation and receiving an autism diagnosis on evaluation.
Significant predictors of diagnostic evaluation receipt included the parent being older or non-Hispanic and the child having private insurance, lower child communication functioning, or receiving Early Intervention services. Significant predictors of an autism diagnosis on evaluation included male child, lower child communication functioning, screening directly in the parent's preferred language, White/non-Hispanic parent, and no parent history of mood disorder.
Children with younger parents, Hispanic ethnicity, relatively higher communication skills, public insurance, and no Early Intervention services were less likely to receive recommended diagnostic care. Reduced likelihood of autism diagnosis after a positive screen in non-White/non-Hispanic subgroups supports previous research indicating issues with M-CHAT-R/F positive predictive power for racial/ethnic minorities. The use of telephonic interpreters to administer screens, as opposed to directly screening in families' preferred languages, may lead to identification of fewer true autism cases. Thus, multilingual clinical staff capacity may improve positive predictive power of autism screening.
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