Supporting the implementation of a state policy on screening for Adverse Childhood Experiences (ACEs) in Federally Qualified Health Centers

项目摘要 不良童年经历（ACE）是指发生在18岁之前的创伤性事件，如 虐待、危及生命的事故、严酷的移徙经历或遭受暴力。ACE是 45%的人经历过至少一次ACE，10%的人经历过三次或更多ACE， 有很高的负面生活后果的风险。ACE在少数民族和移民社区中更为普遍 由于暴露于贫困，歧视，社区暴力，国家灾害和难民的经验。 ACE筛查在识别经历有毒压力的儿童和身体方面具有潜在价值， 与之相关的心理健康状况，如哮喘，多动症和焦虑。然而，它们很少被用于 在健康儿童访问期间提供初级保健。加州州的卫生局局长已经解决了这一问题 通过发布ACE筛选政策来弥补这一差距。从2020年1月开始，加州MediCal的医疗补助医疗保健 计划，将偿还初级保健设置（29美元）使用儿科ACE和相关的生活事件 筛选器（PEARLS）工具，用于在健康访问期间筛选儿童ACE。尽管投资巨大， 在加州和全国范围内，普遍儿童筛查政策的公共卫生价值的证据尚不清楚。 加强筛查工作往往并不能使儿童获得更多的护理， 通过增加耻辱感和强化边缘化群体的缺陷观，加剧了差距。这些结果 这是由于缺乏严格的研究测试适用于儿科的实施策略， 筛选政策。这项混合方法研究将通过完善和测试一项实施战略来填补这一空白 在南加州的一家联邦合格的健康中心进行了多中心对照试验。使用EPIS 框架，我们将采用混合（2型），随机对照试验，采用阶梯楔形设计（n=5 诊所）来测试一个中心假设，即采用多方面实施策略的诊所将 ACE筛选策略的保真度和覆盖范围更高。一个次要的假设将检查公众 ACE政策对儿童患者水平的心理健康服务和症状结果的健康影响。具体 目标是：目标1。完善多方面的实施战略，以支持实施ACE 社区诊所的筛查政策，以及目标2。初步测试可行性、可接受性、保真度和可及性 的实施策略和儿童患者水平的结果ACE政策的影响。这个项目 利用一个难得的机会，试点测试实施战略，以最大限度地发挥全州范围的影响， 旨在改善资源不足环境下儿童健康的政策。

PROJECT SUMMARY Adverse Childhood Experiences (ACEs) are defined as traumatic events occurring before age 18, such as maltreatment, life-threatening accident, harsh migration experiences or exposure to violence. ACEs are pervasive, with 45% experiencing at least one ACE and 10% experiencing three or more ACEs, placing them at high risk for negative life outcomes. ACEs are more prevalent among minority and immigrant communities due to exposure to poverty, discrimination, community violence, national disasters, and refugee experiences. ACEs screenings have potential value in identifying children experiencing toxic stress and the physical and mental health conditions associated with it such as asthma, ADHD and anxiety. Yet, they are seldom used in primary care during well-child visits. The Surgeon General of the state of California has addressed this care gap by issuing an ACEs screening policy. Starting January 2020, MediCal, California's Medicaid health care program, will reimburse primary care settings ($29) for using the Pediatric ACEs and Related Life-events Screener (PEARLS) tool to screen children for ACEs during wellness visits. Despite significant investment in California and nationwide, evidence of the public health value of universal child screening policies is unclear. Increased screening efforts often do not translate into higher access to care for children and may even exacerbate disparities by increasing stigma and reinforcing a deficit view of marginalized groups. These results have been attributed to a lack of rigorous studies testing implementation strategies suited for pediatric screening policies. This mixed-method study will fill this gap by refining and testing an implementation strategy using a multi-site control trial with a Federally Qualified Health Center in Southern California. Using the EPIS framework, we will employ a hybrid (type 2), randomized controlled trial using a stepped-wedge design (n=5 clinics) to test to test a central hypothesis that clinics employing a multifaceted implementation strategy will have higher fidelity and reach of the ACEs screening policy. A secondary hypothesis will examine the public health impact of the ACEs policy on child patient-level mental health service and symptom outcomes. Specific aims are: Aim 1. Refine a multifaceted implementation strategy to support the implementation of the ACEs screening policy in community-based clinics, and Aim 2. Pilot test the feasibility, acceptability, fidelity and reach of the implementation strategy and the impact of the ACEs policy on child patient-level outcomes. This project capitalizes on a rare opportunity to pilot test an implementation strategy to maximize the impact of a state-wide policy intended to improve child health in under-resourced settings.