Vibrant and Healthy Kids Aligning Science, Practice, and Policy to Advance Health Equity (2019) / Chapter Skim
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8 A Systems Approach to Advance Early Development and Health Equity
8 A Systems Approach to Advance Early Development and Health Equity
Pages 545-568
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From page 545... ...
Additionally, better alignment among systems will need to be accompanied by an increase in overall investment in early life: many of the systems best positioned to address early life drivers of health inequities are chronically underresourced, and improved collaboration may only be possible if resources are available to adopt, scale, and spread best practices within a redesigned and better aligned cross-sector ecosystem. There is likely no single, sweeping change that will create a new and better system of care that can address the variety of needs and challenges identified in this report; rather, steady progress integrating and connecting the efforts of the systems already in place, along with improved investments in those systems, will lead incrementally but steadily to improvements in health equity over time.
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From page 546... ...
•• Integrate care and services across the health continuum, including the adoption of models that provide comprehensive support for the whole person by leveraging and connecting existing community resources. •• Support payment reform to allow for upstream investment.
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From page 547... ...
From the perspective of a life course approach -- where failing to invest early means missing critical windows to set positive health trajectories, and the later an intervention comes, the more difficult it is to change negative trajectories -- this fractured approach is an impediment to reaching health equity in the preconception through early childhood periods and beyond. Systems Are Structured to Take the Short-Term View Currently, systems are poorly structured to incentivize long-term thinking and planning.
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From page 548... ...
Systems Take a Narrow View of the Biological and Social Context Scientific and institutional systems tend to segment the biological and social; in the context of early life, they are often poorly set up to address the symbiotic relationship between biological development and social context. Even within settings that address health and development explicitly, such as pediatric clinics, there tends to be segmentation of biological risk (assessed by clinicians or pharmacists)
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From page 549... ...
It will not be improved solely by developing and deploying programs aimed at individuals experiencing poor outcomes -- until the root causes are addressed, negative health outcomes will persist. Young people experience adverse and positive exposures that cumulatively help shape their odds for good health over the life course, but within systems, those exposures occur at
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From page 550... ...
The distinct regulations for different sectors (e.g., Health Insurance Portability and Accountability Act of 1996 in health care and Family Educational Rights and Privacy Act of 1974 in education) have different criteria for data use, and while some allow data to be combined for the purposes of research or evaluation, there are few legal pathways available to make operational use of cross-sector data in ways that would help co-manage common populations or address common root causes with coordinated, cross-sector approaches.
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From page 551... ...
There are currently few validated methodologies for measuring shared savings -- especially given the data-sharing challenges that have already been highlighted -- or mechanisms for capturing those savings and distributing them among the participating partners. Making headway on shared savings models could help create powerful aligned incentives that help cross-sector initiatives create, sustain, and spread their work.
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From page 552... ...
Enhance Detection of Early-Life Adversity and Improve Response Systems As discussed throughout this report, adversities in early life -- including adverse childhood experiences and other adverse experiences or exposure to key social determinants of health (SDOH) , such as housing instability or food insecurity -- help set the odds for poor health outcomes later in life.
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From page 553... ...
Recommendation 8-2: Policy makers and leaders in the health care, public health, social service, criminal justice, early care and education/education, and other sectors should adopt and implement screening for trauma and adversities early in life to increase the likelihood of early detection. This should include creating rapid response and referral systems that can quickly bring protective resources to bear when early-life adversities are detected, through the coordination of cross-sector expertise, as covered in Recommendation 8-1.
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From page 554... ...
However, its effects also are not destiny: effective services can help mitigate the impact of adversity on health across the life course. Most systems are designed to capture discrete data elements about their service domain, but exposure to social adversity or trauma is often contextual, captured via narrative interactions with patients or clients.
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From page 555... ...
Complementary disciplines can be drawn from to create teams that promote transdisciplinary service delivery. This might include traditional service providers and the expanded use of paraprofessionals, community health workers, peer support specialists, parent advisors, or others who bring expertise in, and lived experiences that are relevant to, the communities or populations being served.
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From page 556... ...
This could be accomplished through mentoring programs, outreach into culturally specific communities when recruiting or hiring, or scholarship programs to "plant the seeds" to introduce more diverse communities into fields where some communities are underrepresented. Recommendation 8-4: Policy makers and leaders in the health care, public health, social service, criminal justice, early care and education/education, and other sectors should develop a transdisciplinary and diverse workforce to implement cultur ally competent service delivery models.
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From page 557... ...
Recommendation 8-5: Policy makers and leaders in the health care, public health, social service, criminal justice, early care and education/education, and other sectors should improve access to programs or policies that explicitly provide paren tal or caregiver supports and help build or promote family attachments and functioning by engaging with the families as a cohesive unit. For families with intensive support needs, develop programs or initiatives designed to provide compre hensive wraparound supports along a number of dimensions, such as health care, education, and social services, designed to address needs related to the social determinants of health that are integrated and community based.
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From page 558... ...
New models that integrate services to address the SDOH should follow this model. These include service delivery models that integrate supports across a range of SDOH, especially housing, transportation, food security, and social support, with a particular focus on family social supports and programs that integrate informal social networks into the health care, ECE, and services ecosystem (see Chapter 5 for recommendations on this for the clinical care system and its connections to other sectors)
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From page 559... ...
Value-based structures promote efficiency and impact over quantity of services and encourage upstream investment to address root causes rather than downstream work to deliver services. Payment models that emphasize upstream investment have substantial focus on prevention in health care, ECE, and community services.
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From page 560... ...
The committee has identified important research needs in this report relevant to the chapter topics (see Recommendations 2-2, 4-1, 4-2, and 4-3) ; here, however, the committee recommends strategies focused on how to conduct research differently to help translate science to action across sectors, including needed data to inform subgroup analysis and to elucidate the complex causality related to health inequities to better target interventions across sectors.
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From page 561... ...
Research Methods • Explore alternative methods to address complex causality. Ran domized controlled trials (RCTs)
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From page 562... ...
Research Content • Promote research that explicitly seeks to understand the inter connected mechanisms of health inequities. Health equity has
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From page 563... ...
In addition, the biological and psychosocial responses to these mechanisms vary across the life course, with some developmental periods of high plasticity offering critical windows for establish ing long-term trajectories for health outcomes. Understanding the root causes of inequities allows actions to be taken to pre vent them; understanding the mechanisms by which root causes shape inequities helps promote more effective intervention when prevention is less than perfect, and understanding variation in responsiveness to those mechanisms across the life course will help ensure interventions are optimally targeted for maximum impact.
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From page 564... ...
What is lacking are good tools for measuring the various systemic and personal factors that influence and interact in complex ways to shape health outcomes over the life course. In the absence of such measures, designing the right kinds of system change remains a challenge.
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From page 565... ...
This means it is not enough to just have a good measure of caregiver attachment or access to health care -- it is necessary to have good measures of how those constructs interact to collectively set the odds of healthy early-life development and why systems present some populations with a greater or lesser probability of exposure to those constructs. FIGURE 8-1 Leveraging early opportunities to achieve health equity across the life course: A conceptual framework.
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From page 566... ...
Rather, the committee conceptualizes health equity as a probabilistic challenge, with each element in the model contributing some adjustment to the odds of experiencing healthy development in early life and continued good health across the life course. Each factor contributes a probability that someone experiencing that factor will have good health outcomes; a person's overall odds of experiencing good health are a cumulative function of all of those probabilities.
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From page 567... ...
Improving methods to assess complex causality. As outlined in Recommendation 8-8, perhaps the biggest challenge facing health equity research is that of complex causality. As noted, many of the preferred tools of science, such as RCTs, are designed to control for and isolate single causes rather than embrace complex, interrelated causality that may include multilevel, multidirectional, and nested effects.
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From page 568... ...
. CONCLUSION These measurement needs represent a significant barrier to advancing the understanding of the biological and social pathways by which early life experiences are translated into health inequities, and the committee calls for improved measurement and research methodologies that can advance the state of the science and better inform effective societal responses.
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