It is known that social determinants influence children?s health trajectories, particularly for low-income children. Pediatric primary care provides a unique opportunity to address children?s social conditions; however, recent national data demonstrates that few providers routinely screen for unmet needs at visits. Our prior work has focused on developing a pediatric primary care-based intervention, ?WE CARE,? aimed at addressing poor families? material needs ? food security, employment, parental education, housing stability, household heat, and childcare ? by systematically screening for these needs and referring families to existing community-based services. To date, we have tested WE CARE primarily in community health centers (CHCs); our RCT demonstrated WE CARE?s efficacy on parental receipt of community-based resources. Although demonstrating WE CARE?s impact in this setting is important, over 80% of low-income children receive care from providers in traditional pediatric practices (i.e. non-CHCs). Given the Affordable Care Act?s mandate for high-value, patient- centered primary care and pediatric professional guidelines, along with WE CARE?s efficacy data, we believe we are well-positioned to test and implement WE CARE in traditional pediatric practices. We propose a large- scale, Hybrid Type 2 effectiveness-implementation trial in twenty eight pediatric practices in the US. A stepped wedge study cluster RCT design will be used to implement WE CARE in all practices using two common strategies used to integrate systems-based interventions into primary care ? our previously facilitated ?on-site? strategy in which content experts provide training sessions and on-going consultation; and a self-directed ?web-based? method modeled after the American Academy of Pediatrics? practice transformation strategy. The proposed study?s specific aims are to: 1) demonstrate the non-inferiority of the self-directed, web-based strategy for implementing WE CARE, in comparison to the facilitated on-site strategy; 2) demonstrate WE CARE?s effectiveness on increasing parental receipt of community resources; and 3) assess the sustainability of WE CARE in pediatric practices. We hypothesize that WE CARE will have equivalent fidelity via the two strategies. Based on our prior work, we hypothesize that WE CARE will significantly increase parental receipt of community resources six months post-visit compared to usual care. We also expect WE CARE to be sustained 1-, 2-, and 3-years post-implementation. We expect to gather data from over 9,000 chart reviews, 2,800 parent-child dyads, and 150 providers and office staff. Our proposal is innovative because it challenges current pediatric practice for addressing social determinants at visits. This proposal has significant public health implications for the delivery of primary care to low-income children and is aligned with the mission of the NICHD. Our long-term goal is to disseminate an evidence-based intervention that systematically addresses the social determinants of health to pediatric practices that provide care to low-income children throughout the US.

Public Health Relevance

Approximately 2 in 5 children are low-income; poverty can detrimentally affect health beginning in childhood leading to worse health in adulthood, thereby reducing society?s workforce and productivity. This study will help determine the public health impact of a pediatric-based intervention that addresses the social determinants of health and is implemented within primary care, 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)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Research Project (R01)
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Dissemination and Implementation Research in Health Study Section (DIRH)
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Lee, Karen
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Boston Medical Center
United States
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