Showing posts with label public health. Show all posts
Showing posts with label public health. Show all posts

Tuesday, September 15, 2015

The Great Divide: Examining Social Determinants of Health

By: Joann Schulte  DO, MPH; Editorial Board Member  
       And they lived happily ever after.  Surely you've heard that phrase ending fairy tales or rags to riches stories.  The plot is basically poor boy or girl pulls himself or herself up by the bootstraps with minimal help from anybody else. That myth has endured ever since Horatio Alger started penning his stories in the 1890s.  The reality is that most people who make themselves a success have help along the way from parents, teachers or somebody who cared and took an interest.  Of course,  children who face adversity have dreams, but often have barriers that Horatio Alger just didn't mention.
     One factor that gets short shrift in such stories is how the hero or heroine started out. Specifics such as dealing with hunger or  having to worry about apartment infestations may not be described in detail in a hard luck story, but these issues are common in reality.  Basics like food insecurity, poor housing or a stressed out single parent are among the social determinants of health (SDH) that can crush a child's dreams early on.  The toxic stress model suggests that social determinants of health often disrupt normal physiological processes, get "under a child's skin" and put a child's future and dreams at risk.
       Pediatricians often try to help individual children who go hungry or live in rat infested housing.  One patient at a time is good, but doesn't fix a community.  Recently  innovative programs called Medical - Legal Partnerships have shown some success in addressing SDH on a  broader community scale.
      Research by Lovegrove,et al. (doi:10.1542/peds.2015-2092), published this month in Pediatrics, documents some successes achieved in Ohio.  That's where the Division of General and Community Pediatrics at Cincinnati Children's Hospital Medical Centers has paired with the Legal Aid Society of greater Cincinnati.  The partnership is between pediatricians and attorneys who have experience helping those trying to overcome their poverty status..
      The pediatricians, who provide care for 15,000 children, did an anonymous survey of parents asking what unaddressed needs their children had.   The survey found that 29 % of parents reported living in poor housing with conditions such as cockroaches or mold.  One in five parents reported financial problems limiting their abilities to buy medication for themselves.  Thirty percent of children lived in household where food insecurity was a problem and 15% of families with infants had to stretch their allotted formula to last long enough to get their next allotment.
      Working together, the physicians and attorneys who comprise  the Cincinnati Child Health Law Partnership (Child HeLP) have identified and improved a cluster of substandard housing  areas where problems included pest infestations, broken windows and water leaks.  They also worked  to provide sufficient formula through donations to food banks that helped more than 1,500 families feed their infants.
       The Cincinnati program and others like it often use Maslow's hierarchy of needs   to assess common needs.   The pyramid assesses human needs, starting at a physiological base with food and shelter and progressing to self actualization (see Figure).  The programs then implement community interventions that benefit multiple children and their families with these needs.  The article by Longrove et al. provide a good overview of a process that can link clinical and community resources in programs that can intervene in economic, environmental and psychosocial areas.  That's a good way to reshuffle at least part of the deck that is often stacked against children from poor families.  A better start to the story is more likely to produce a happy ending.

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Monday, August 3, 2015

Sources for Infant Care Advice: What Are They and How Well Is That Advice Received?

By: Lewis First, MD, MS; Editor-in-Chief       

          A key component of every health maintenance visit is the advice we provide to parents who bring their infants and children to us.  In fact as pediatricians, we pride ourselves on making sure that advice is evidence-based and individualized for each patient and family under our care.  That being said, parents seek advice not just from pediatricians, but from birth hospital nurses, family and the media—at least according to a new study by Eisenberg et al. (2015-0551) being released this week. 
     The authors surveyed more than 1000 mothers from across the country regarding five key advice topics—immunization, breastfeeding, sleep position, sleep location and pacifier use. While the good news is that pediatricians are the most prevalent source of advice, mothers self-reported that they got no advice on sleep location or pacifier use, and about 1/5 of the sample stated they got no advice on breastfeeding or sleep position.  To find out how the other sources of advice performed, read the study yourself—although be ready to learn just how popular or unpopular family members and the media can be in also offering advice to your patients.   
     So do you agree with the findings in this study and are you surprised how often key areas of advice are not being received by families from pediatricians?  Does this mean the advice is not given, or it just doesn’t register given everything else a family wanted to learn during a visit?  To provide some further input on this study and what it means to all who practice, Drs. Scott Krugman and Carolyn Fowler provide their interesting opinion in an accompanying commentary (doi: 10.1542/peds.2015-1826).   
      Take my advice—and read this study and commentary and share the findings with families of infants as you provide your anticipatory guidance that will help insure they stay healthy in that important first year of life.

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Tuesday, February 17, 2015

Racial-Ethnic Disparities in Managing Children with Type 1 Diabetes: Do They Exist?

     Everyone would agree that the care they provide to one child versus another shouldn't differ on the basis of race or ethnicity—but unfortunately, disparities in the management of diabetes do exist on that basis—as per some important findings contained in a study being released this week by Willi et al. (doi:10.1542/peds.2014-1774). 
The authors looked at disparities as documented in a national type 1 diabetes clinical registry for more than 10,000 children and teens between 1 year and 18 years of age with the disease.  Even after adjusting for socioeconomic status, differences existed in insulin treatment methods and treatment outcomes. 
So why does this happen—and just what are the disparities noted?  Are results due to different management strategies or perhaps it is because the genetics of the disease differs by race and ethnicity resulting in different achievable levels of hemoglobin A1C and other diabetic outcome measures. 
The authors offer some insight into the findings they have analyzed, but we have also asked diabetologist Dr. Stuart Chalew (doi: 10.1542/peds.2014-4136) to share his perspective on this study via a commentary released simultaneously.  Both the study and commentary are thought provoking, and we hope will generate some conversation from our readers as well via a response in the comments below, an e-letter or comment on our Facebook or Twitter pages.  Do you agree with the findings relative to your own practice?  We look forward to your comments as to whether the disparities noted are ones we can improve upon.

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Tuesday, December 16, 2014

Clearing the Air on Teens at Risk for Smoking E-Cigarettes,

With the growing prevalence of e-cigarette use in adults, one cannot help but wonder what the trends are among adolescents and whether a similar increase in their use can be influential in legislating stricter usage regulations for minors.

Willis et al.(doi:10.1542/peds.2014-0760) studied more than 1,900 teens attending high school in Hawaii to determine whether they were using e-cigarettes, conventional cigarettes, and/or both, as well as other risk factors such as alcohol and marijuana associated with such smoking behaviors.

The results may surprise you. The authors note that 17 percent of teens were users of e-cigarettes only, 3 percent cigarettes only, and 12 percent dual users with e-cigarette users showing less risk than conventional or dual smokers but still more than those who don’t smoke at all.

So what kind of teen uses an e-cigarette and not a conventional cigarette and why? What risks are associated with use of e-cigarettes relative to users of conventional cigarettes or dual usage?

This study smokes out the answers to these questions and more and will hopefully have you asking more specifically about e-cigarettes during health maintenance visits with teens in your practice. Perhaps sharing with these patients the associated risk-taking behaviors they should be wary of will help curb their experimenting with these behaviors—and even if not, will make you more aware that they may be occurring in the setting of using these devices.

Are you finding more of your teen patients using e-cigarettes and not conventional cigarettes? Have you asked them why? We hope you will share your thoughts on this new concerning trend by responding to this blog, sending us an e-letter over on our journal website, or perhaps posting your comments on our Facebook or Twitter pages.

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