“Beyond just the four walls of the clinic”: The roles of health systems caring for refugee, immigrant and migrant communities in the United States

This article is part of the Research Topic ‘Health Systems Recovery in the Context of COVID-19 and Protracted Conflict’IntroductionRefugee, immigrant and migrant (hereafter referred to as “immigrant”) communities have been inequitably affected by the COVID-19 pandemic. There is little data to help us understand the perspectives of health systems on their role, in collaboration with public health and community-based organizations, in addressing inequities for immigrant populations. This study will address that knowledge gap.MethodsThis qualitative study used semi-structured video interviews of 20 leaders and providers from health systems who cared for immigrant communities during the pandemic. Interviewees were from across the US with interviews conducted between November 2020–March 2021. Data was analyzed using thematic analysis methods.ResultsTwenty individuals representing health systems participated with 14 (70%) community health centers, three (15%) county hospitals and three (15%) academic systems represented. The majority [16 health systems (80%)] cared specifically for immigrant communities while 14 (70%) partnered with refugee communities, and two (10%) partnered with migrant farm workers. We identified six themes (with subthemes) that represent roles health systems performed with clinical and public health implications. Two foundational themes were the roles health systems had building and maintaining trust and establishing intentionality in working with communities. On the patient-facing side, health systems played a role in developing communication strategies and reducing barriers to care and support. On the organizational side, health systems collaborated with public health and community-based organizations, in optimizing pre-existing systems and adapting roles to evolving needs throughout the pandemic.ConclusionHealth systems should focus on building trusting relationships, acting intentionally, and partnering with community-based organizations and public health to handle COVID-19 and future pandemics in effective and impactful ways that center disparately affected communities. These findings have implications to mitigate disparities in current and future infectious disease outbreaks for immigrant communities who remain an essential and growing population in the US

mHealth Technology Design and Evaluation for Early Childhood Health Promotion: Systematic Literature Review

BackgroundRecent increases in smartphone ownership among underserved populations have inspired researchers in medicine, computing, and health informatics to design and evaluate mobile health (mHealth) interventions, specifically for those supporting child development and growth. Although these interventions demonstrate possible effectiveness at larger scales, few of these interventions are evaluated to address racial disparities and health equity, which are known factors that affect relevance, uptake, and adherence in target populations. ObjectiveIn this study, we aimed to identify and document the current design and evaluation practices of mHealth technologies that promote early childhood health, with a specific focus on opportunities for those processes to address health disparities and health equity. MethodsWe completed a systematic literature review of studies that design and evaluate mHealth interventions for early childhood health promotion. We then analyzed these studies to identify opportunities to address racial disparities in early- and late-stage processes and to understand the potential efficacy of these interventions. ResultsAcross the literature from medical, computing, and health informatics fields, we identified 15 articles that presented a design or evaluation of a parent-facing health intervention. We found that using mobile-based systems to deliver health interventions was generally well accepted by parents of children aged <5 years. We also found that, when measured, parenting knowledge of early childhood health topics and confidence to engage in health-promoting behaviors improved. Design and evaluation methods held internal consistency within disciplines (eg, experimental study designs were the most prevalent in medical literature, while computing researchers used user-centered design methods in computing fields). However, there is little consistency in design or evaluation methods across fields. ConclusionsTo support more interventions with a comprehensive design and evaluation process, we recommend attention to design at the intervention (eg, reporting content sources) and system level; interdisciplinary collaboration in early childhood health intervention development can lead to large-scale deployment and success among populations. Trial RegistrationPROSPERO CRD42022359797; https://tinyurl.com/586nx9a

Family-Centered Care for US Children With Special Health Care Needs: Who Gets It and Why?

OBJECTIVE: The goal was to examine racial/ethnic and language disparities in family-centered care (FCC) and in FCC components for children with special health care needs (CSHCN). METHODS: Bivariate and multivariate logistic regression analyses of data from the 2005-2006 National Survey of CSHCN were performed. RESULTS: A total of 66% of CSHCN with a health visit in the past year received FCC. In adjusted analyses, we found lower odds of FCC for Latino (odds ratio: 0.53 [95% confidence interval: 0.45-0.63]), African-American (odds ratio: 0.60 [95% confidence interval: 0.52-0.69]), and other (odds ratio: 0.58 [95% confidence interval: 0.43-0.78]) children, compared with white children, and for children in households with a non-English primary language (odds ratio: 0.48 [95% confidence interval: 0.36-0.64]), compared with those in households with English as the primary language. These disparities persisted after adjustment for child health (condition severity and emotional, behavioral, and developmental needs), socioeconomic (poverty level, parental education, household composition, and residing in a metropolitan statistical area), and access (insurance type, usual source of care, and having a personal physician) factors. Of these factors, only condition severity was significantly associated with the racial/ethnic disparities; none was significantly associated with the language disparities. Disparities were found for Latino and African-American children and children in households with a non-English primary language for the FCC components of time spent with the provider and sensitivity to the family's values and customs. CONCLUSIONS: Robust FCC racial/ethnic and language disparities exist for CSHCN; initial efforts to address these disparities should focus on increasing provider time and cultural sensitivity. Pediatrics 2010; 125: 1159-116

Promoting Child Development During the COVID-19 Pandemic: Parental Perceptions of Tele-Home Visits in Early Head Start Programs

ObjectiveThe COVID-19 pandemic prompted families to receive Early Head Start (EHS) home-based services virtually. This qualitative study evaluated parental perceptions of EHS tele-home visits.MethodsEHS parents who had transitioned to tele-home visits using any video-chat platform were recruited to participate in a Spanish or English virtual focus group that assessed their perceptions of tele-home visits. Using an iterative, consensus-seeking inductive content analysis approach, themes and subthemes were identified.ResultsThirty-five mothers of children newborn to 3-years-old, where the majority were Latino and Spanish-speaking, participated in four focus groups. Several patterns pertaining to technology, child engagement, child learning and development, and parent-home visitor relationship emerged in the qualitative analysis. Mothers revealed varying degrees of digital proficiency, device preference, and technology challenges. Mothers reported variability in child engagement and concerns with missed socialization opportunities for children as a results of tele-home visits, but also reported increased self-efficacy in supporting child development, positive relationships with their home visitor, and overall satisfaction with services.ConclusionParents revealed tele-home visits have the potential to be a viable service delivery method for EHS home-based programs. While parents perceived increased engagement and an uncompromised parent-home visitor relationship, they revealed areas of needed support that would optimize the use of tele-home visits

General Pediatricians' Views on Allocating More Time in Primary Care Practice to Children with Special Health Care: Results from a National Survey

Objective. To describe the proportion, characteristics, and attitudes of pediatricians who want to allocate more time in primary care to children with special health care needs (CSHCN). Methods. Data from a national random sample mail survey of 1000 pediatricians were used to examine attitudes towards allocating more time to CSHCN, and associated preferences towards changes to primary care. Results. Sixty percent (n=502) of eligible subjects participated. Forty-five percent of pediatricians reported that, if they could redesign their practices to maximize efficiency and effectiveness, they would allocate more time to providing care to CSHCN. After multivariate adjustment, respondents who wanted to allocate more time to CSHCN were more likely to want to allocate more time to care coordination with staff (OR 3.6[1.7-7.4, p?0.001]) and non-visit communication with parents (OR 3.0[1.7-5.5], p?0.001), and were more likely to prefer delegation of well-child care services to non-physicians (OR 5.9[2.8-12.5], p?0.001). Inadequate reimbursement was reported as the most important obstacle to implementing such changes in their practices. Conclusions. These findings suggest that a substantial number of pediatricians would ideally allocate more time in primary care to CSHCN. Systems of care that could support such a change should be investigated

Well-Child Care Clinical Practice Redesign at a Community Health Center

Background: Community health centers (CHCs) are a key element of the health care safety net for underserved children. They may be an ideal setting to create well-child care (WCC) clinical practice redesign to drastically improve WCC delivery. Objective: To examine the perspectives of clinical and administrative staff at a large, multisite urban CHC on alternative ways to deliver WCC services for low-income children aged 0 to 3 years. Methods: Eight semistructured interviews were conducted with 4 pediatric teams (each consisting of 1 pediatrician and 2 medical assistants) and 4 CHC executive/administrative staff (Medical Director, COO, CEO, and Nurse Supervisor). Discussions were recorded, transcribed, and analyzed using the constant comparative method of qualitative analysis. Salient themes included WCC delivery challenges and endorsed WCC clinical practice redesign solutions. Results: The 3 main WCC delivery challenges included long wait times due to insurance verification and intake paperwork, lack of time for parent education and sick visits due to WCC visit volume, and absence of a system to encourage physicians to use non–face-to-face communication with parents. To address WCC delivery challenges, CHC providers and administrators endorsed several options for clinical practice redesign in their setting. These included use of a health educator in a team-based model of care, a previsit tool for screening and surveillance, Web site health education, a structured system for non–face-to-face (eg, phone) parent communication, and group visits. Conclusion: CHC-specific strategies for WCC clinical practice redesign endorsed by a large, multisite safety net clinic may lead to more efficient, effective, and family-centered WCC for low-income populations

Well-Child Care Clinical Practice Redesign for Serving Low-Income Children

Our objective was to conduct a rigorous, structured process to create a new model of well-child care (WCC) in collaboration with a multisite community health center and 2 small, independent practices serving predominantly Medicaid-insured children. Working groups of clinicians, staff, and parents (called "Community Advisory Boards" [CABs]) used (1) perspectives of WCC stakeholders and (2) a literature review of WCC practice redesign to create 4 comprehensive WCC models for children ages 0 to 3 years. An expert panel, following a modified version of the Rand/UCLA Appropriateness Method, rated each model for potential effectiveness on 4 domains: (1) receipt of recommended services, (2) family-centeredness, (3) timely and appropriate follow-up, and (4) feasibility and efficiency. Results were provided to the CABs for selection of a final model to implement. The newly developed models rely heavily on a health educator for anticipatory guidance and developmental, behavioral, and psychosocial surveillance and screening. Each model allots a small amount of time with the pediatrician to perform a brief physical examination and to address parents' physical health concerns. A secure Web-based tool customizes the visit to parents' needs and facilitates previsit screening. Scheduled, non-face-to-face methods (text, phone) for parent communication with the health care team are also critical to these new models of care. A structured process that engages small community practices and community health centers in clinical practice redesign can produce comprehensive, site-specific, and innovative models for delivery of WCC. This process, as well as the models developed, may be applicable to other small practices and clinics interested in practice redesign