Focusing on Children's Health Community Approaches to Addressing Health Disparities: Workshop Summary (2009) / Chapter Skim
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Appendix E: Clinical Health Care Practice and Community Building: Addressing Racial Disparities in Healthy Child Development
Appendix E: Clinical Health Care Practice and Community Building: Addressing Racial Disparities in Healthy Child Development
Pages 87-112
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From page 87... ...
Addressing these child health disparities is particularly important, as childhood and adolescence establish health trajectories that extend throughout a person's life span.1 These disparities in child health conditions by race and ethnicity also cooccur with other disparities in child outcomes -- from educational achievement to child welfare and justice system involvement. This high degree of co-occurrence warrants attention to identifying some common etiology for these disparities.2 Clearly, good child health involves • imely and appropriate (and therefore culturally sensitive)
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From page 88... ...
In fact, child health practitioners6 and their institutions can play a contributing role in supporting child health and healthy child development across all these points. As an example, Figure 3-2 shows that when the pediatric practitioner's role is broadly defined and practiced, the set of healthy child development outcomes that should be at least partially addressed through well-child care for young children involves identifying potential concerns on all these points and at least beginning to address them.7 Defining child health and the responsibilities of the health care community broadly is particularly important in distressed or vulnerable neighborhoods, where child health outcomes are poorest and where children of color disproportionately live.8 While there is a limited clinical research base regarding the effectiveness of more holistic pediatric approaches to healthy child development, there is also little within current research to indicate an inability to develop such pediatric practice.9 Further, there are promising programs with evidence of success in improving health outcomes and reducing disparities that deserve attention and support, particularly as they connect children and families to other community-building activities.
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Table E-1 shows that these child health disparities are similar in size to those found for educational and social outcomes. In other words, disparities related to healthy child development and school success are equally profound to those related to specific health conditions.
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From page 90... ...
(0–17) /100,000 81.7 84.1 108.9 D Healthy Child Development Indicators/Education Below basic 4th-grade reading proficiency 22% 54% 50% F Below basic 8th-grade math proficiency 18% 53% 45% F 15–24 dropout rates 6.0% 10.4% 22.4% G Noncompletion of high school 24.1% 48.8% 46.8% H
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From page 91... ...
birth rate/1,000 females 2.6% 6.3% 8.3% A Living in high-risk neighborhood 1.7% 20.3% 25.3% K Median household net worth $74,900 $7,500 $9,750 L Child Population 2000 population 44,027,087 10,880,696 12,342,259 Percentage of total child population 60.9% 15.1% 17.1% Projected 2020 population 42,459,109 12,392,102 18,923,344 Percentage of total 52.9% 15.4% 23.6% SOURCES: A Annie E
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Des Moines, IA: State Early Childhood Policy Technical Assistance Network. ������������������������������������������� Net worth and asset ownership of households: 1998 and 2000.
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Except for the South, these high-vulnerability tracts are concentrated in metropolitan, largely inner-city, neighborhoods, with the highest concentrations of these in the Northeast. While pointing to the importance of place-based approaches to improving child health and healthy child development, particularly important for
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From page 94... ...
In short, successful efforts to reduce child health and other disparities by race and ethnicity will have to make substantial gains within these highvulnerability census tracts, simply due to the very substantial percentage of the child population of color that resides in those tracts. In addition, however, available evidence also shows that the health and healthy development child outcomes are the poorest for both African American and Hispanic children who live within these census tracts.14 Developing successful efforts in these tracts and neighborhoods likely requires considerable attention to addressing environmental and neighborhood,15 as well as individual and family, conditions that exist there, which also have been referred to as "toxic stress" that harms brain development in children.16 Neighborhood conditions include physical indicators such as levels of safety and exposure to environmental toxins, but also role models and social ties and connections that look out for children.
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Indian/Native Alaskan 100 40.3 27.6 21.0 11.1 % Native Hawaiian and other PI 100 50.6 29.9 13.4 6.1 % Other 100 47.6 26.6 15.4 10.4 SOURCE: Census data, 2000.
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From page 96... ...
As stated in the introduction, good child health and healthy child development involves • imely and appropriate (and therefore culturally sensitive) medical t care for illness and injury and screening to detect and treat congeni tal abnormalities and chronic as well as acute health conditions; • good hygiene, nutrition, and exercise; • table and nurturing families who provide constant and consistent s supervision; • safe environments that do not contain toxic elements; • ocial institutions that reinforce healthy lifestyles and behaviors s and provide opportunities for growth and development; and • ocial and psychological supports that foster resiliency and positive s identity.
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From page 97... ...
tors weigh much more heavily in producing current disparities.20 Further, although often not considered as an objective or goal (i.e., the dependent variable in a regression equation) , there is at least case study evidence that child health insurance coverage and clinical pediatric services can play a role in improving healthy child development and educational and social outcomes as well as specific health outcomes.21 On the third assumption, which is the lynchpin assumption to interventions that involve clinical practice changes, survey research shows that the pediatric practitioner is often the only professional who sees children and their families and is also in a position to assess health and development.
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(0-5) FIGURE E‑1 Children's healthy development: Who sees young children?
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From page 99... ...
Reducing child health, education, and other disparities by race and ethnicity will require increased efforts to develop such strategies and changed child health practices, coupled with evaluation designs that do not rely upon clinical trials as the sole methodology for attributing causality. On the fifth assumption relating to the geographic concentration of risk factors, there is strong evidence of the spatial concentration of children of color who experience health disparities (see previous section)
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From page 100... ...
Preventable costs related to asthma, obesity, lead poisoning, school dropout, homelessness and lack of employability, and justice system involvement (including costs to society in victimization and incarceration expenses) collectively amount to hundreds of billions, if not trillions of dollars, annually.34 Developing strategies to reduce health disparities and disparities in healthy child development are warranted from a fiscal as well as a moral perspective.
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From page 101... ...
The next section highlights two such approaches. THE ROLE OF CHILD HEALTH PRACTICE IN REDUCING DISPARITIES IN CHILD HEALTH AND HEALTHY DEVELOPMENT -- TWO STRATEGIC APPROACHES Although research is limited on strategies that incorporate clinical and community-building practices, there is promising evidence that exists around specific programmatic approaches that, explicitly or implicitly, adopt a theory of change similar to that presented in the last section.36 Two of these -- "Help Me Grow" in Connecticut and the "East End Partnership with Families" in Richmond, Virginia -- are described here.
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Child Development Community Liaisons The third core component of Help Me Grow is the child development community liaison, who works closely with the care coordinators in identifying and matching community services. Liaisons work to continuously build the comprehensive community resources database that care coordinators use in their work; they also serve as consultants to the care coordinators on specific cases, in researching for resources that can address specific needs.
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From page 103... ...
It has increased child health care providers' understanding and use of other professional services such as Part C and diagnoses and followup clinical services for specific mental and developmental health conditions, with at least one follow-up visit achieved for more than 90 percent of all children, according to the most recent report.38 In addition, it has created a bridge for addressing a variety of more general parental issues and concerns that can affect children's healthy development. Approximately one-quarter of the referrals to care coordinators relate to issues of parenting stress, isolation, or lack of parenting knowledge, or to issues of child discipline and behavior.
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Harris Health Center; • parent resource network, including advocacy training and sup a port, peer networking, and a variety of support groups, including a kinship care support group, a single parents support group, and a teen "girl talk" group; • hild guidance services, involving community-based mental health, c school-based mental health, and preventive mental health services; and • variety of community programs developed through the partner a ship's work and partner leadership, based upon needs identified by parents and youth and specific opportunities for securing needed resources identified by the partnership and its members, including such activities as youth drug abuse counseling, teen grief counsel ing, "raising a reader" programming, obesity prevention program ming, and male mentoring and fatherhood programming. The starting point for the connection with families is the Vernon J
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From page 105... ...
It also assumes that a critical mass of activity will, in fact, change community social capital and community resiliency to produce community improvements related to healthy child development that are more than the sum of individual program parts. At a minimum, testing this assumption requires research methodologies that extend beyond randomized controlled trials, particularly as assignment to a treatment or control group would violate the fundamental, inclusive approach being taken to producing changes in healthy child development.
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. As case illustrations, the Help Me Grow and East End Partnership with Families examples provide illustrations of organic and holistic approaches to improving healthy child development that start with clinical practice but extend into their communities to produce improvements in healthy child development.
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From page 107... ...
The disconnect that minorities may face between that dominant culture belief and their own opportunity (because of institutional racism and/or cultural clashes in undergirding values and expectations) can be cause for alienation, anger, and anomie, all to the detriment of health and healthy development.
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5-14. 14 Geomapping of vital records statistics and birth outcomes is increasingly common and shows the spatial concentration of infant mortality, low birth weight, and entry into prenatal care.
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2004. Very low birth weight in African American infants: The role of maternal exposure to interpersonal racial discrimination.
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This includes the ability for disproof, includ ing disproof of the role of participant-led change as sufficient or necessary for improving healthy child development outcomes. 41 Polansky, N
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Care coordina tion and targeted case management are essential for helping children and their families develop bridges between clinical services and other supports necessary for their healthy development and need to be part of a financing system. As another simple illustration, the Reach Out and Read program has demonstrated a positive effect upon early literacy and is a low-cost intervention that pediatricians generally value.
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