Addressing Psychosocial Topics in Group Well-Child Care: A Multi-Method Study With Immigrant Latino Families

Group Well Child Care for Mothers with Opioid Use Disorder: Framework for Implementation

OBJECTIVE

For parents with opioid use disorder (OUD) and their children, group well child care (WCC) is an under-studied intervention that may reduce stigma, increase quality of care, and improve clinical outcomes. We explored barriers and facilitators to this intervention using an implementation science framework.

METHODS

A qualitative study was conducted from October 2020-March 2021 as part of the planning phase of a cluster-randomized trial of group WCC. Parent participants were recruited from one urban, university-affiliated OUD treatment center to participate in semi-structured telephone interviews. Eligible parents had a child under two years old and were English speaking. Clinician participants were recruited from a nearby pediatric primary care practice. Inductive thematic analysis of interview responses was led by two investigators using open coding procedures.

RESULTS

Thirty-one parents and thirteen pediatric clinicians participated in the interviews. Most parents (68%) reported that they would be likely or very likely to bring their child to the OUD treatment center for WCC. Six themes emerged describing perceived implementation barriers, including intervention difficulty, complexity, and potential negative outcomes such as loss of privacy. Six themes emerged as implementation facilitators: (1) focus on parental OUD and recovery, (2) peer support, (3) accessibility and coordination of care, (4) clinician skill and expertise in parental OUD, (5) increased time for patient care, and (6) continuity of care.

CONCLUSIONS FOR PRACTICE

Parents and clinicians expressed multiple perceived benefits of this intervention. Identified barriers and facilitators will inform implementation and evaluation of group WCC within one OUD treatment program.

Multilevel Factors Associated With Participation in Group Well-Child Care

OBJECTIVE

To identify factors associated with participation in group well-child care (GWCC), wherein families share preventive health care visits.

METHODS

We extracted electronic health record data of mother-infant dyads with infants born 2013-18 at Yale New Haven Hospital and followed at the primary care center. Using chi-square analysis and multivariate logistic regression, we examined the extent to which 1) maternal/infant characteristics and recruitment timing were associated with GWCC initiation and continued engagement and 2) initiation was associated with primary care visits.

RESULTS

Of 2046 eligible mother-infant dyads, 11.6% initiated GWCC. The odds of initiation were higher among mothers with Spanish versus English primary language (odds ratio: 2.36 [95% confidence interval: 1.52-3.66]), with 1 child versus ≥ 3 children (1.58 [1.13-2.22]), and of non-Hispanic Black versus non-Hispanic White infants (2.72 [1.39-5.32]). Initiation was lower among infants born in 2016 (0.53 [0.32-0.88]) and 2018 (0.29 [0.17-0.52]) versus 2013. Among GWCC initiators with follow-up data (n = 217), continued engagement (n = 132, 60.8%) was positively associated with maternal age of 20-29 years (2.85 [1.10-7.34]) and > 30 years (3.46 [1.15-10.43]) compared with< 20 years, and mothers with 1 child versus ≥ 3 (2.28 [1.04-4.98]). GWCC initiators, versus non-initiators, had 5.06 times higher adjusted odds of attending > 9 primary care appointments in the first 18 months (95% confidence interval: 3.74-6.85).

CONCLUSIONS

As evidence builds on health and social benefits of GWCC, recruitment efforts may gain from considering multi-level socio-economic, demographic, and cultural factors associated with GWCC participation. Higher participation among systemically marginalized groups may present unique opportunities for family-based health promotion to mitigate health inequities.

Clinicians' Perspectives on Equitable Health Care Delivery in Group Well-Child Care

OBJECTIVE

To explore clinicians' perspectives about the impact of group well-child care (GWCC) on equitable health care delivery.

METHODS

In this qualitative study, we conducted semistructured interviews with clinicians engaged in GWCC recruited via purposive and snowball sampling. We first conducted a deductive content analysis using constructs from Donabedian's framework for health care quality (structure, process, and outcomes) followed by inductive thematic analysis within these constructs.

RESULTS

We completed 20 interviews with clinicians who deliver or research GWCC in 11 institutions across the United States. Four major themes around equitable health care delivery in GWCC emerged from clinicians' perspectives: 1) shifts in power dynamics (process); 2) enabling relational care, social support, and a sense of community (process, outcome); 3) centering multidisciplinary care delivery around patient and family needs (structure, process, and outcomes); and 4) unaddressed social and structural barriers limit patient and family participation.

CONCLUSIONS

Clinicians perceived that GWCC enhances equity in health care delivery by shifting hierarchies in clinical visits and promoting relational, patient, and family-centered care. However, potential opportunities exist to further address provider implicit bias in group care delivery and structural inequities at the level of the health care institution. Clinicians underscored the need to address barriers to participation so that GWCC can more fully enhance equitable health care delivery.

A Conceptual Framework for Group Well-Child Care: A Tool to Guide Implementation, Evaluation, and Research

OBJECTIVE

To use scoping review methods to construct a conceptual framework based on current evidence of group well-child care to guide future practice and research.

METHODS

We conducted a scoping review using Arksey and O'Malley's (2005) six stages. We used constructs from the Consolidated Framework for Implementation Research and the quadruple aim of health care improvement to guide the construction of the conceptual framework.

RESULTS

The resulting conceptual framework is a synthesis of the key concepts of group well-child care, beginning with a call for a system redesign of well-child care to improve outcomes while acknowledging the theoretical antecedents structuring the rationale that supports the model. Inputs of group well-child care include health systems contexts; administration/logistics; clinical setting; group care clinic team; community/patient population; and curriculum development and training. The core components of group well-child care included structure (e.g., group size, facilitators), content (e.g., health assessments, service linkages). and process (e.g., interactive learning and community building). We found clinical outcomes in all four dimensions of the quadruple aim of healthcare.

CONCLUSION

Our conceptual framework can guide model implementation and identifies several outcomes that can be used to harmonize model evaluation and research. Future research and practice can use the conceptual framework as a tool to standardize model implementation and evaluation and generate evidence to inform future healthcare policy and practice.

Examining Processes of Care Redesign: Direct Observation of Group Well-Child Care

We sought to describe processes of psychosocial screening and discussion with immigrant Latino families in the context of group well-child care. We conducted longitudinal direct observations of the 1-, 2-, 4-, and 6-month visits of 7 group well-child care cohorts at an academic pediatric clinic using unstructured observations of visit and group processes as well as structured observations to code facilitators' behavior. A range of psychosocial and social determinants of health topics were incorporated into discussions. In general, providers skillfully navigated group discussions, but inconsistently introduced the visit purpose. Asking participants to define psychosocial terms (eg, stress) and conversations about managing fussy infants were effective strategies to engage families in psychosocial discussions (eg, about postpartum depression). Some challenges with workflow were identified. Strategies to enhance screening and discussion of psychosocial topics may benefit from adaptation to maximize the effectiveness of this care mechanism.

Group well-child care model for Latino children in immigrant families: Adapting to and learning from the coronavirus disease 2019 (COVID-19) context

INTRODUCTION

Group well-child care (GWCC) is an alternative to traditional pediatric well-child care designed to increase parental social support and peer learning. This mixed methods study explored the adaptation and implementation of GWCC to a virtual format during coronavirus disease 2019 (COVID-19 pandemic) among Spanish-speaking Latino immigrant families.

METHOD

Interviews were conducted with eight providers and 10 mothers from May through September 2020. Qualitative analyses used a priori codes based on an implementation science framework. Quantitative data included demographics, the COVID-19 Impact Scale, and virtual group attendance. Bivariate analyses identified correlates of virtual visit attendance.

RESULTS

Eighty percent of mothers reported the pandemic had moderately or extremely impacted at least one major life domain such as daily life, food security, or family conflict. Of 27 mothers offered virtual groups, 67% attended. Mothers who attended virtual groups reported lower English proficiency (p = .087) and fewer friends and family members with COVID-19 (M = 1.0 vs. 5.1, p < .05) than those who did not attend. Women described virtual GWCC as acceptable and a source of social support. Some described differences in group dynamics compared with in-person groups and had privacy concerns. Providers noted scheduling and billing challenges affecting feasibility and sustainability. They reported that visits with good attendance were productive. Mothers and pediatric providers offered recommendations to improve feasibility and privacy and address sustainability.

DISCUSSION

Competing demands for those most impacted by COVID-19 may outweigh benefits of attendance. Virtual Spanish language GWCC appears acceptable and feasible for Spanish speaking Latina mothers. Thematic analysis and recommendations identify areas of improvement. (PsycInfo Database Record (c) 2022 APA, all rights reserved).