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.

Public Health Relevance

Over 2 in 5 children are low-income, with racial and ethnic minorities disproportionately affected. Poverty can detrimentally impact health beginning in childhood leading to worse health as adults, thereby reducing society's workforce and productivity. This study is an important step in determining the public health impact of a primary care-based intervention that addresses the social determinants of health at pediatric visits, with the goal of closing the health gaps between low-income and high-income populations. It is aimed to achieve health equity and eliminate disparities-an overarching goal of Healthy People 2020.

National Institute of Health (NIH)
National Institute on Minority Health and Health Disparities (NIMHD)
Research Project (R01)
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Special Emphasis Panel (ZMD1-DRI (01))
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Alvidrez, Jennifer L
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Boston Medical Center
United States
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