Reducing Socioeconomic Disparities in Health at Pediatric Visits

描述（由申请人提供）：社会经济弱势群体经历多种健康差异。生命历程研究表明，这些差异始于童年时期，由于暴露于“有毒压力”（定义为长期暴露于逆境）而导致成年疾病的生物学嵌入。儿童初级保健——特别是在联邦合格卫生中心（FQHCs）——提供了一个独特的公共卫生机会来解决这一压力，因为儿童卫生保健几乎普及，儿童早期就诊的频率很高。我们之前的工作重点是开发和检验以儿科为基础的干预模式“WE CARE”的有效性，以解决家庭未满足的物质需求——这对低收入儿童来说是一种潜在的有毒压力。具体来说，WE CARE解决了6个关键的物质需求——食品安全、就业、父母教育、住房稳定、家庭供暖和儿童保育——通过在儿科就诊时系统地筛选并将家庭转介到现有的社区资源。我们的R00研究的初步数据表明，该模型在增加提供者推荐和父母在儿童出生后第一年接受社区服务方面是有效的；我们现在建议在8个fqhc进行大规模、多地点随机有效性试验，并进行实施评估，其中We CARE策略通过在现有临床系统中嵌入筛查/转诊流程并利用同行引导的患者导航来增强。该研究的具体目标是：1)确定增强WE CARE模式在提供者推荐和家庭接受社区资源方面的有效性；2)确定模型对低收入儿童卫生保健服务利用和儿童发展的影响，并探讨其对慢性健康状况-肥胖发病的影响；3)深入了解该模式的背景和实施情况，以提高其在全国fqhc的传播和实施潜力。我们假设增强的We CARE模式将增加提供者推荐和家庭接受社区资源。主要基于生命历程和累积路径模型，以及我们的R00结果，我们假设这种基于儿科的模型将减少暴露于未满足的物质需求，从而减少慢性压力，并改善生命前三年的健康轨迹。我们预计将跟踪1400多名低收入儿童，主要是少数民族儿童（每个治疗组700名儿童），从出生到3岁。我们的建议是创新的，因为它采用了一种新的干预方法——在低收入儿童的儿科就诊中系统地解决健康的社会决定因素——以减少健康方面的终身社会经济差异。这一建议对向低收入儿童提供初级保健具有重大的公共卫生影响，并解决了NIMHD的一个优先领域。我们的长期目标是传播和实施一种儿科护理模式，重点是通过fqhc在国家一级解决健康的社会决定因素。

DESCRIPTION (provided by applicant): Socioeconomically disadvantaged populations experience multiple health disparities. Life course research suggests that these disparities begin in childhood with the biological embedding of adult disease as a result of exposure to "toxic stress," defined as prolonged exposure to adversity. Pediatric primary care-particularly at Federally Qualified Health Centers (FQHCs)-provides a unique public health opportunity to address this stress given the near universal reach of child health care and the frequency of visits in early childhood. Our prior work has focused on developing and examining the efficacy of a pediatric-based intervention model, "WE CARE", on addressing families' unmet material needs-a potent toxic stress for low-income children. Specifically, WE CARE addresses six key material needs-food security, employment, parental education, housing stability, household heat, and childcare-by systematically screening and referring families to available community-based resources at pediatric visits. Preliminary data from our R00 study suggests the model is efficacious in increasing provider referrals and parental receipt of community-based services in the child's first year of life; however, a subset of referred parents did not contact any resources We now propose a large-scale, multi-site randomized effectiveness trial, along with an implementation evaluation, at eight FQHCs, in which the WE CARE strategy is augmented by embedding screening/referral processes within existing clinical systems and by utilizing peer-led patient navigation. The proposed study's specific aims are to: 1) determine the effectiveness of the augmented WE CARE model on provider referrals and family receipt of community-based resources; 2) determine the model's impact on low-income children's utilization of health care services and child development and explore its impact on the onset of a chronic health condition-obesity; and 3) gain insight into the context and implementation of the model in order to enhance its dissemination and implementation potential at FQHCs nationally. We hypothesize that the augmented WE CARE model will increase provider referrals and family receipt of community resources. Based primarily on the life course and cumulative pathways models, along with our R00 results, we hypothesize that this pediatric- based model will reduce exposure to unmet material needs resulting in less chronic stress and improved health trajectories in the first three years of life. We expect to follow a cohort of over 1,400 low-incom, predominantly minority, children (>700 per treatment arm) from birth to age 3. Our proposal is innovative because it applies a new interventional approach-addressing social determinants of health systematically at low-income children's pediatric visits-to reducing lifelong socioeconomic disparities in health. This proposal has significant public health implications for the delivery of primary care to low-income children and addresses a NIMHD priority area. Our long-term goal is dissemination and implementation of a pediatric care model focused on addressing the social determinants of health at the national level through FQHCs.