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，这些差异开始于儿童时期，由于暴露于“有毒压力”（定义为长期暴露于逆境）而导致成人疾病的生物学嵌入。儿科初级保健，特别是在联邦合格的卫生中心（CIMCs）-提供了一个独特的公共卫生机会，以解决这一压力，因为几乎普遍的儿童保健和访问的频率在幼儿期。我们之前的工作集中在开发和检查基于儿科的干预模式的有效性，“我们关心”，解决家庭的未满足的物质需求-一个潜在的有毒压力低收入儿童。具体来说，我们关心解决六个关键的物质需求-粮食安全，就业，父母教育，住房稳定，家庭供暖和儿童保育-通过系统地筛选和转介家庭在儿科访问可用的社区资源。从我们的R 00研究的初步数据表明，该模式是有效的，在增加供应商转介和父母接受社区为基础的服务，在儿童的第一年的生活;然而，一部分被推荐的父母没有联系任何资源。我们现在提出一个大规模的、多地点的随机有效性试验，沿着实施评估，在8个儿童健康中心，其中，通过在现有临床系统中嵌入筛查/转诊流程以及利用同行引导的患者导航来增强WE CARE战略。这项研究的具体目标是：1）确定扩大的WE CARE模式在提供者转介和家庭接受社区资源方面的有效性; 2）确定该模式对低收入儿童使用医疗保健服务和儿童发展的影响，并探讨其对慢性健康状况-肥胖症的影响;以及3）深入了解该模式的背景和实施情况，以加强其在全国范围内的宣传和实施潜力。我们假设，增强的WE CARE模式将增加供应商转介和家庭接收社区资源。主要基于生命过程和累积途径模型，沿着我们的R 00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。我们预计将对1,400多名低收入儿童（主要是少数民族儿童）（每个治疗组>700名）从出生到3岁进行随访。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。该提案对向低收入儿童提供初级保健具有重大的公共卫生影响，并涉及NIMHD的优先领域。我们的长期目标是传播和实施儿科护理模式，重点是通过国家一级的儿童保健中心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.