Enhancing Pediatric Palliative Care for Latino Children and Their Families: A Review of the Literature and Recommendations for Research and Practice in the United States

A scoping review of Spanish language pediatric digital health interventions

OBJECTIVE

Despite the growing number of Hispanic/Latino families in the United States, major concerns are reported when navigating the healthcare system. Monolingual Spanish-speaking families may experience compounded barriers given the inconsistent availability of Spanish resources and services in traditional healthcare settings. Digital health interventions have the potential to alleviate some barriers in healthcare for these individuals. This scoping review summarizes the state of the literature on the development, adaptation, and implementation of pediatric Spanish-language digital health interventions offered to Spanish-speaking families in the United States to better understand current cultural-sensitivity practices and strategies implemented by researchers.

METHODS

A search in major databases was completed in May 2024. Articles that discussed the development, implementation, or outcome of any digital health intervention primarily oriented to a Spanish-speaking pediatric population in the United States were included. Telephone- and telehealth-only interventions were excluded.

RESULTS

A total of 44 articles were reviewed, representing 30 unique digital health interventions. Most covered preventive health topics, utilized SMS texting, and were intended primarily for parents/caregivers. Only 22 articles discussed specific methods to culturally tailor the intervention. The most common methods implemented were advisory boards and collecting qualitative data from parents/caregivers and youth. About 50% of articles reported results related to efficacy, acceptability, and feasibility.

CONCLUSION

While similar methods are implemented to develop and adapt these interventions, there is ample variation throughout the process. Including and learning directly from intended users in the adaptation and development phases of digital health interventions can help create quality and culturally appropriate digital health programs for families.

A Geospatial Analysis of Barriers to Cleft Lip and Palate Care in the United States

OBJECTIVE

This study evaluates the geospatial distribution of cleft lip and/or cleft palate (CL/P) care in the United States, assesses disparities between families with and without one-hour proximity to CL/P care, and recommends interventions for improving access.

DESIGN

We identified American Cleft Palate Craniofacial Association-approved CL/P teams and calculated a one-hour driving radius around each clinic. We then used census data to compare risk factors for developing cleft (i.e., incidence risk factors) and obstacles to care (i.e., access risk factors) between counties with and without one-hour proximity.

RESULTS

We identified 187 CL/P teams in 45 states. Most were in the South (n = 60, 32.0%), though children in the Middle Atlantic had the greatest access to care. Alabama, Mississippi, Tennessee, and Kentucky had the least access. Children without access were 39% more likely to have gestational tobacco exposure, 8% more likely to have gestational obesity exposure, and 28% less likely to have health insurance (p < 0.01). Children without access in the South were 29% more likely to have a low birth weight and 46% more likely to be living below the poverty line (p < 0.01). Children with access were twice as likely to live in immigrant families and 7-times more likely to speak English as a second language.

CONCLUSIONS

Pronounced disparities affect patients with and without one-hour access to CL/P care. Interventions should address care costs for patients living furthest without access and language barriers for patients with access that speak English as a second language.

Supporting Migrant Children in Pediatric Settings: Lessons Learned from the US Migrant Humanitarian Crisis Response

This article examines the influx of migrants to the United States and highlights current global and local immigration trends. The authors focus on migrant children-specifically the effect of migration trauma in the context of humanitarian responses to the intentional movement of migrants to Democrat-led cities across the US to humanize the compounded effects of migration trauma, restrictive immigration policies, and the current resettlement landscape for migrants. The authors are directly involved with supporting migrant arrivals who have relocated to Chicago from the southern border, and apply field knowledge to articulate current barriers to accessing health care and best practices within pediatric settings supporting migrant arrivals. Clinical and practice implications for medical providers in pediatric settings are included. The article also highlights the role of interdisciplinary collaboration in providing health care to asylum-seeking migrants and implications for transdisciplinary workforce development in this area. [Pediatr Ann. 2024;53(5):e171-e177.].

The Integration of the Resolved Through Sharing Perinatal Bereavement Follow-up Model with Latinx Cultural Values: A Case Illustration

The Resolved Through Sharing (RTS) Perinatal bereavement model is an approach used for working with birthing people and their families who have experienced a perinatal loss. RTS is designed to help families cope with their grief and integrate the loss in their lives, meet the needs of the families during the initial crisis, and offer comprehensive care to each member of the family affected by the loss. This paper utilizes a case illustration to describe a year-long bereavement follow-up of an undocumented underinsured Latina woman who suffered a stillbirth during the beginning of the COVID-19 pandemic and the hostile anti-immigrant policy during the Trump presidency. The case illustration is based on a composite case of several Latina women who had pregnancy losses with similar outcomes, demonstrating how a perinatal palliative care (PPC) social worker provided ongoing bereavement support to a patient who experienced a stillbirth. The case illustrates how the PPC social worker utilized the RTS model, incorporated the patient’s cultural values, and acknowledged systemic challenges which resulted in the patient receiving comprehensive, holistic support that aided her emotional and spiritual recovery from her stillbirth. The author ends with a call to action for providers in the field of perinatal palliative care to incorporate practices that allow for greater access and equity for all birthing people.

Measuring Pediatric Palliative Care Quality: Challenges and Opportunities

Pediatric palliative care (PPC) programs vary widely in structure, staffing, funding, and patient census, resulting in inconsistency in service provision. Improving the quality of palliative care for children living with serious illness and their families requires measuring care quality, ensuring that quality measurement is embedded into day-to-day clinical practice, and aligning quality measurement with healthcare policy priorities. Yet, numerous challenges exist in measuring PPC quality. This paper provides an overview of PPC quality measurement, including challenges, current initiatives, and future opportunities. While important strides toward addressing quality measurement challenges in PPC have been made, including ongoing quality measurement initiatives like the Cambia Metrics Project, the PPC What Matters Most study, and collaborative learning networks, more work remains. Providing high-quality PPC to all children and families will require a multi-pronged approach. In this paper, we suggest several strategies for advancing high-quality PPC, which includes 1) considering how and by whom success is defined, 2) evaluating, adapting, and developing PPC measures, including those that address care disparities within PPC for historically marginalized and excluded communities, 3) improving the infrastructure with which to routinely and prospectively measure, monitor, and report clinical and administrative quality measures, 4) increasing endorsement of PPC quality measures by prominent quality organizations to facilitate accountability and possible reimbursement, and 5) integrating PPC-specific quality measures into the administrative, funding, and policy landscape of pediatric healthcare.

Pediatric Goals of Care Communication: A Socioecological Model to Guide Conversations

The purpose of this article is to explore factors that influence pediatric patients and their parents during provider-led goals-of-care conversations. Our framework can help providers enhance holistic communication by approaching difficult topics (ie, quality of life, end of life) with an understanding of the multilayered external influences that affect patient/parent decision making. A 5-layer model is presented that describes facilitators to conversations about quality goals of care and advance directives. Each year, complex health conditions (a) affect approximately 500 000 children in the United States, 8600 of whom meet current palliative care criteria, and (b) account for over 7 million child deaths globally. Nurses can use knowledge of the unique values and culture of families with children who have complex health conditions to support them by providing high quality, ongoing goals-of-care conversations, especially if their access to pediatric palliative care is limited.

Home-Based Care for Children with Serious Illness: Ecological Framework and Research Implications

Care for U.S. children living with serious illness and their families at home is a complex and patchwork system. Improving home-based care for children and families requires a comprehensive, multilevel approach that accounts for and examines relationships across home environments, communities, and social contexts in which children and families live and receive care. We propose a multilevel conceptual framework, guided by Bronfenbrenner’s ecological model, that conceptualizes the complex system of home-based care into five levels. Levels 1 and 2 contain patient and family characteristics. Level 3 contains factors that influence family health, well-being, and experience with care in the home. Level 4 includes the community, including community groups, schools, and providers. Level 5 includes the broader regional system of care that impacts the care of children and families across communities. Finally, care coordination and care disparities transcend levels, impacting care at each level. A multilevel ecological framework of home-based care for children with serious illness and families can be used in future multilevel research to describe and test hypotheses about aspects of this system of care, as well as to inform interventions across levels to improve patient and family outcomes.

Communication Challenges Faced by Spanish-Speaking Caregivers of Children with Medical Complexity: a Qualitative Study

BACKGROUND

Communication between caregivers and healthcare providers is important in the delivery of high-quality healthcare for children with medical complexity (CMC). Hispanic children face many challenges in access to healthcare services. Our objective was to describe the communication challenges faced by Spanish-speaking parents with limited English proficiency (SSP-LEP).

METHODS

This was a qualitative study of 70 children of Spanish-speaking caregivers, enrolled in a complex care program of a tertiary care children's hospital in North Carolina. Secondary source data were abstracted logs of care coordination tasks maintained by the program's two bilingual care coordinators for a median observation period of 45 months, and complemented by data from care coordinator interviews. Data were entered and coded in ATLAS.ti. Using thematic content analysis and an iterative process, we identified recurrent themes related to communication challenges of Spanish-speaking caregivers.

RESULTS

Median age of children was 5 years; 51% were girls; 97% had Medicaid; and 3% were uninsured. Seven children died during the observation period. Three major themes were identified as follows: (1) caregivers faced many communication challenges primarily because of language barrier. (2) Multiple factors at caregiver, provider, and system levels, in addition to language barrier, contributed to communication challenges. (3) Communication challenges had serious consequences for CMC. These consequences were lessened by bilingual coordinators.

CONCLUSION

SSP-LEP face unique communication challenges resulting in negative impact on the healthcare of their CMC. Bilingual coordinators can help improve communication between SSP-LEP and their healthcare providers. Interventions to address communication challenges of Spanish-speaking caregivers are warranted.

Barriers to Accessing Medical Care for Hispanic Individuals With Craniofacial Conditions

In the United States, having limited access to health care has been an ongoing concern that could cause detrimental effects for minority populations, specifically the Hispanic population. Numerous barriers to accessing health care were identified for both pediatric and adult Hispanic patients who were born with craniofacial conditions. Barriers that were determined to impact Hispanic patients with craniofacial conditions from receiving medical and health services included language and communication, patient-health care provider relationships, socioeconomic status and finances, insurance status, timely access to appointments, citizenship and immigration status, and lack of family and social support. Interventions for these barriers were also proposed to increase support for Hispanic patients. Lamentably, there is scant research that investigates how these barriers affect this special population, despite the limitations that they have in their ability to access health care. In addition, these barriers to treatment have dire consequences for individuals with craniofacial conditions. The findings and proposed interventions discussed in this review article provide measures to minimize these barriers and define ways to benefit Hispanic patients with craniofacial conditions.

Barriers to Accessing Medical Care for Hispanic Individuals With Craniofacial Conditions

In the United States, having limited access to health care has been an ongoing concern that could cause detrimental effects for minority populations, specifically the Hispanic population. Numerous barriers to accessing health care were identified for both pediatric and adult Hispanic patients who were born with craniofacial conditions. Barriers that were determined to impact Hispanic patients with craniofacial conditions from receiving medical and health services included language and communication, patient-health care provider relationships, socioeconomic status and finances, insurance status, timely access to appointments, citizenship and immigration status, and lack of family and social support. Interventions for these barriers were also proposed to increase support for Hispanic patients. Lamentably, there is scant research that investigates how these barriers affect this special population, despite the limitations that they have in their ability to access health care. In addition, these barriers to treatment have dire consequences for individuals with craniofacial conditions. The findings and proposed interventions discussed in this review article provide measures to minimize these barriers and define ways to benefit Hispanic patients with craniofacial conditions.

Quantifying the Language Barrier-A Total Survey of Parents' Spoken Languages and Local Language Skills as Perceived by Different Professions in Pediatric Palliative Care

To date, there are no specific figures on the language-related characteristics of families receiving pediatric palliative care. This study aims to gain insights into the languages spoken by parents, their local language skills and the consistency of professional assessments on these aspects. Using an adapted version of the “Common European Framework of Reference for Languages”, the languages and local language skills of parents whose children were admitted to an inpatient pediatric palliative care facility (N = 114) were assessed by (a) medical staff and (b) psychosocial staff. Nearly half of the families did not speak the local language as their mother tongue. The most frequently spoken language was Turkish. Overall, the medical staff attributed better language skills to parents than the psychosocial staff did. According to them, only 27.0% of mothers and 38.5% of fathers spoke the local language at a high level while 37.8% of mothers and 34.6% of fathers had no or rudimentary language skills. The results provide important information on which languages pediatric palliative care practitioners must be prepared for. They sensitize to the fact that even within an institution there can be discrepancies between the language assessments of different professions.

HPNA 2019-2022 Research Agenda: Development and Rationale

Building on the strong work of previous research agendas (2009-2012, 2012-2015, 2015-2018), the Hospice and Palliative Nurses Association Research Advisory Council developed the 2019-2022 Research Agenda in consultation with Hospice and Palliative Nurses Association (HPNA) membership and assessment of major trends in palliative nursing. The HPNA Research Advisory Council identified 5 priority areas and asked subject experts in each area to summarize the state of the science, identify critical gaps, and provide recommendations for future research. This document expands the executive summary published on the HPNA website (www.advancingexpertcare.org/hpna/) and provides supporting evidence for the 2019-2022 recommendations. The 5 priority areas are as follows: (1) pediatric hospice and palliative nursing research; (2) family caregiving; (3) interprofessional education and collaborative practice; (4) big data science, precision health, and nursing informatics; and (5) implementation science.

Delivering Pediatric Palliative Care: From Denial, Palliphobia, Pallilalia to Palliactive

Among the over 21 million children with life-limiting conditions worldwide that would benefit annually from a pediatric palliative care (PPC) approach, more than eight million would need specialized PPC services. In the United States alone, more than 42,000 children die every year, half of them infants younger than one year. Advanced interdisciplinary pediatric palliative care for children with serious illnesses is now an expected standard of pediatric medicine. Unfortunately, in many institutions there remain significant barriers to achieving optimal care related to lack of formal education, reimbursement issues, the emotional impact of caring for a dying child, and most importantly, the lack of interdisciplinary PPC teams with sufficient staffing and funding. Data reveals the majority of distressing symptoms in children with serious illness (such as pain, dyspnea and nausea/vomiting) were not addressed during their end-of-life period, and when treated, therapy was commonly ineffective. Whenever possible, treatment should focus on continued efforts to control the underlying illness. At the same time, children and their families should have access to interdisciplinary care aimed at promoting optimal physical, psychological and spiritual wellbeing. Persistent myths and misconceptions have led to inadequate symptom control in children with life-limiting diseases. Pediatric Palliative Care advocates the provision of comfort care, pain, and symptom management concurrently with disease-directed treatments. Families no longer have to opt for one over the other. They can pursue both, and include integrative care to maximize the child's quality of life. Since most of the sickest children with serious illness are being taken care of in a hospital, every children's hospital is now expected to offer an interdisciplinary palliative care service as the standard of care. This article addresses common myths and misconceptions which may pose clinical obstacles to effective PPC delivery and discusses the four typical stages of pediatric palliative care program implementation.