Understanding critical factors associated with integration of community health workers into health and hospital systems

Community health worker (CHW) models have been shown to improve health behaviors and health outcomes and reduce cost, particularly among low-income underserved populations. Consequently, health systems are increasingly employing CHWs to provide health services in clinical environments. A growing body of the literature suggests that effective integration of CHWs within the healthcare system is important to achieve the desired outcomes, but the question of how to achieve effective integration is less clear. This study seeks to explore the integration of CHWs within a large state university health system to identify factors critical to the effective integration of CHWs into the clinical care environment. We conducted a qualitative descriptive multiple embedded case study of the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within the UI Health System that currently employ CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review. In total, six sub-units were enrolled, and 17 interviews were conducted with CHWs (n = 9), and administrators or healthcare providers (n = 8). Fourteen factors related to effective CHW integration were identified and organized in four categories: individual, team, organization, and community. Findings suggest that in addition to commonly recognized elements of effective CHW models including training, supervision, and the presence of a champion, programs must consider the organizational context in which the program is positioned as well as the ways in which both CHWs and the organization engage with communities served. This research can serve as a roadmap for health systems that seek to integrate CHWs within healthcare services and can be used to promote best practice in CHW integration.

Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis

STUDY OBJECTIVES

To examine the risk of increased health care utilization (HU) linked to individual sleep disorders in children with chronic medical conditions.

METHODS

Medicaid claims data from a cohort of 16,325 children enrolled in the Coordinated Healthcare for Complex Kids (CHECK) project were used. Sleep disorders and chronic medical conditions were identified using International Classification of Diseases, Ninth, and 10th Revision, codes. Three HU groups were identified based on participants' prior hospitalizations and emergency department (ED) visits in the 12 months prior to enrollment: low (no hospitalization or ED visit), medium (1-2 hospitalizations or 1-3 ED visits), and high (≥ 3 hospitalizations or ≥ 4 ED visits). The odds of being in an increased HU group associated with specific sleep disorders after controlling for confounding factors were examined.

RESULTS

Children with chronic medical conditions and any sleep disorder had nearly twice the odds (odds ratio = 1.83; 95% confidence interval: 1.67-2.01) of being in an increased HU group compared with those without a sleep disorder. The odds of being in the increased HU group varied among sleep disorders. Only sleep-disordered breathing (odds ratio = 1.51; 95% confidence interval : 1.17-1.95), insomnia (odds ratio = 1.46; 95% confidence interval : 1.06-2.02), and circadian rhythm sleep disorder (odds ratio = 2.45; 95% confidence interval : 1.07-5.64) increased those odds. Younger age and being White were also linked to increased HU.

CONCLUSIONS

Sleep disorders are associated with increased risk of heightened HU (ED visits and/or hospitalizations) in children with chronic medical conditions. This risk varies by specific sleep disorders. These findings indicate the need for careful evaluation and management of sleep disorders in this high-risk cohort.

CITATION

Adavadkar PA, Brooks L, Pappalardo AA, Schwartz A, Rasinski K, Martin MA. Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis. J Clin Sleep Med. 2024;20(4):595-601.

Extending the Theory of Normative Social Behavior: Collective Norms, Opinion Leadership, and Masking During the COVID-19 Pandemic

Novel, public behaviors, such as masking, should be susceptible to normative influence. This paper advances the theory of normative social behavior by considering a new set of moderators of normative influence - superdiffuser traits - and by clarifying the antecedents and consequences of exposure to collective norms. We use data from a two-wave survey of a cohort living in one U.S. county during the pandemic (N = 913) to assess normative effects on masking. We also used a bipartite network (based on people shopping for food in the same stores) to examine exposure to collective norms. The results show different superdiffuser traits have distinct effects on the relationship between perceived injunctive norms and masking intentions. Exposure to collective norms influences masking, but this influence depends on how people interact with their social environments. Network analysis shows that behavioral homophily is a significant predictor of selective exposure to collective norms earlier (but not later) in the pandemic. Implications for understanding normative influence in a context where opinion leadership matters are discussed.

Community-Based Organizations Leading Research Efforts: Preliminary Findings from the Chicagoland CEAL Program's COVID-19 Vaccine Uptake and Intention Survey

BACKGROUND

To foster community engaged research in the communities most impacted by COVID-19, the National Institutes of Health (NIH) formed 21 teams of Community Engagement Alliance Against COVID-19 Disparities (CEAL). The national CEAL initiative developed a Common Survey to investigate attitudes and behaviors to the COVID-19 vaccine and clinical trials. This article describes survey implementation at the Chicagoland CEAL Program (CCP).

METHODS

This community-based participatory research project was the result of a strong collaboration between academic institutions, and a community-based non-profit health equity-focused partner organization. The survey implementation was developed and refined with strong input from CHWs, participants, and staff in the partner organizations and institutions. Survey data were collected with Qualtrics, a web-based survey tool.

RESULTS

Survey implementation resulted in data collection for 852 participants during the period 12/18/2021-02/18/2023. Excluding participants on the basis of missing data resulted in a sample of 690, 601 of which (87.10%) indicated that they had received at least one dose or intended to get vaccinated. Overall, 54 (7.83%) respondents reported that they had not received the vaccine and were not planning to.

CONCLUSION

Hard to reach populations present two unique challenges in emerging infectious disease events. Reaching populations vulnerable to poor outcomes with vaccines was essential to addressing the COVID-19 pandemic. Additionally, learning about barriers and hesitancy toward vaccine uptake is difficult in these communities. CCP's partnership of five academic institutions, a community research center, and a community-based non-profit health equity-focused organization shows what is possible when traditional models of research and inquiry are reconsidered for community-based participatory research. Results shown here are drawn from a collaboratively designed and implemented survey, collected in person, with over 90% completion.

Delivering COVID-19 Vaccine via Trusted Social Services: Program Evaluation Results from the Chicagoland CEAL Program

To describe the reach, implementation, and sustainability of COVID-19 vaccination programs delivered by social service community organizations. Five academic institutions in the Chicagoland CEAL (Community Engagement Alliance) program partnered with 17 community organizations from September 2021-April 2022. Interviews, community organizations program implementation tracking documents, and health department vaccination data were used to conduct the evaluation. A total of 269 events were held and 5,432 COVID-19 vaccines delivered from May 2021-April 2022. Strategies that worked best included offering vaccinations in community settings with flexible and reliable hours; pairing vaccinations with ongoing social services; giving community organizations flexibility to adjust programs; offering incentives; and vaccinating staff first. These strategies and partnership structures supported vaccine uptake, community organization alignment with their missions and communities' needs, and trust. Community organizations delivering social services are local community experts and trusted messengers. Pairing social service delivery with COVID-19 vaccination built individual and community agency. Giving COs creative control over program implementation enhanced trust and vaccine delivery. When given appropriate resources and control, community organizations can quickly deliver urgently needed health services in a public health crisis.

Adoption and Discontinuance of Innovation Packages: A Longitudinal Study of Transitions in COVID-19 Mitigation

The past decades have seen growing interest and application of interventions targeting the change of multiple behaviors at once. We advance this work by using the diffusion of innovations theory (DOI) to consider constellations of behaviors as innovation packages: multiple innovations that are logically related, interdependent in their use or effects, and often promoted as a set (Rogers, 2003). In addition, we embraced DOI's focus on behavioral decisions as a continual process that can include adoption and discontinuance over time, especially as new innovations (e.g., COVID-19 vaccine) appear. To that end, we conducted a latent transition analysis of COVID-19 mitigation behaviors (N = 697; 97% received a COVID-19 vaccine) across three time points in the pandemic: initial outbreak; a secondary, record-breaking rise in cases; and after the CDC recommended that fully vaccinated adults could discontinue wearing masks. This analysis allowed us to identify latent classes based on shared behavioral patterns and transitions between classes over time. The results showed evidence of three possible packages: (a) a package of traditional, symptom-management behaviors (covering coughs and sneezes, staying home if ill, and seeking medical care), (b) a package of just-novel COVID-19 behaviors (wearing masks, keeping six feet apart, and avoiding mass gatherings), and (c) a package of all COVID-19 mitigation behaviors. Movement between classes exemplified adoption and discontinuance of different packages, as well as widespread discontinuance with the replacement innovation: COVID-19 vaccines. Additional analyses showed that increases in hope were associated with sustained and delayed adoption; decreases in social approval were associated with discontinuance. Future directions in theorizing around innovation packages are discussed.

Coordinated Health Care Interventions for Childhood Asthma Gaps in Outcomes (CHICAGO) plan

Background

Evidence-based strategies to improve outcomes in minority children with uncontrolled asthma discharged from the emergency department (ED) are needed.

Objectives

This multicenter pragmatic clinical trial was designed to compare an ED-only intervention (decision support tool), an ED-only intervention and home visits by community health workers for 6 months (ED-plus-home), and enhanced usual care (UC).

Methods

Children aged 5 to 11 years with uncontrolled asthma were enrolled. The change over 6 months in the Patient-Reported Outcomes Measurement Information System Asthma Impact Scale score in children and Satisfaction with Participation in Social Roles score in caregivers were the primary outcomes. The secondary outcomes included guideline-recommended ED discharge care and self-management.

Results

Recruitment was significantly lower than expected (373 vs 640 expected). Of the 373 children (64% Black and 31% Latino children), only 63% completed the 6-month follow-up visit. In multivariable analyses that accounted for missing data, the adjusted odds ratios and 98% CIs for differences in Asthma Impact Scores or caregivers' Satisfaction with Participation in Social Roles scores were not significant. However, guideline-recommended ED discharge care was significantly improved in the intervention groups versus in the UC group, and self-management behaviors were significantly improved in the ED-plus-home group versus in the ED-only and UC groups.

Conclusions

The ED-based interventions did not significantly improve the primary clinical outcomes, although the study was likely underpowered. Although guideline-recommended ED discharge care and self-management did improve, their effect on clinical outcomes needs further study.

Oral Health Behaviors for Young Low-Income Urban Children during the COVID-19 Pandemic: A Mixed Methods Analysis

This research assessed oral health behaviors changes in urban families with young children during the stay-at-home period of the COVID-19 pandemic (Nov 2020-August 2021). Survey data on oral health behaviors were collected in homes at three points before COVID-19, and via phone during COVID-19. A subset of parents and key informants from clinics and social service agencies completed in-depth interviews via video/phone. Of the 387 parents invited, 254 completed surveys in English or Spanish (65.6%) during COVID-19. Fifteen key informant interviews (25 participants) and 21 family interviews were conducted. The mean child age was 4.3 years. Children identified as mainly Hispanic (57%) and Black race (38%). Parents reported increased child tooth brushing frequency during the pandemic. Family interviews highlighted changes in family routines that impacted oral health behaviors and eating patterns, suggesting less optimal brushing and nutrition. This was linked to changed home routines and social presentability. Key informants described major disruptions in oral health services, family fear, and stress. In conclusion, the stay-at-home period of the COVID-19 pandemic was a time of extreme routine change and stress for families. Oral health interventions that target family routines and social presentability are important for families during times of extreme crisis.

Association between neighborhood disadvantage and children's oral health outcomes in urban families in the Chicago area

Purpose

The prevalence of childhood caries in urban Chicago, compared with national and state data, indicates that neighborhood context influences oral health. Our objective was to delineate the influence of a child's neighborhood on oral health outcomes that are predictive of caries (toothbrushing frequency and plaque levels).

Methods

Our study population represents urban, Medicaid-enrolled families in the metropolitan Chicago area. Data were obtained from a cohort of participants (child-parent dyads) who participated in the Coordinated Oral Health Promotion (CO-OP) trial at 12 months of study participation (N = 362). Oral health outcomes included toothbrushing frequency and plaque levels. Participants' neighborhood resource levels were measured by the Area Deprivation Index (ADI). Linear and logistic regression models were used to measure the influence of ADI on plaque scores and toothbrushing frequency, respectively.

Results

Data from 362 child-parent dyads were analyzed. The mean child age was 33.6 months (SD 6.8). The majority of children were reported to brush at least twice daily (n = 228, 63%), but the mean plaque score was 1.9 (SD 0.7), classified as "poor." In covariate-adjusted analyses, ADI was not associated with brushing frequency (0.94, 95% CI 0.84-1.06). ADI was associated with plaque scores (0.05, 95% CI 0.01-0.09, p value = 0.007).

Conclusions

Findings support the hypothesis that neighborhood-level factors influence children's plaque levels. Because excessive plaque places a child at high risk for cavities, we recommend the inclusion of neighborhood context in interventions and policies to reduce children's oral health disparities. Existing programs and clinics that serve disadvantaged communities are well-positioned to support caregivers of young children in maintaining recommended oral health behaviors.

Oral health behaviors for young low-income urban children during the COVID-19 pandemic: a mixed methods analysis

This research assessed oral health behaviors changes in urban families with young children during the stay-at-home period of the COVID-19 pandemic. Survey data on oral health behaviors were collected in homes at three points over one year before COVID-19, and then via phone during COVID-19. Multivariate logistic regression was used to model tooth brushing frequency. A subset of parents completed in-depth interviews via video/phone that expanded on oral health and COVID-19. Key informant interviews via video/phone were also conducted with leadership from 20 clinics and social service agencies. Interview data were transcribed and coded, and themes were extracted. COVID-19 data collection went from Nov 2020 - August 2021. Of the 387 parents invited, 254 completed surveys in English or Spanish (65.6%) during COVID-19. Fifteen key informant (25 participants) and 21 parent interviews were conducted. The mean child age was approximately 4.3 years. Children identified as mainly Hispanic (57%) and Black race (38%). Parents reported increased child tooth brushing frequency during the pandemic. Parent interviews highlighted significant changes in family routines that impacted oral health behaviors and eating patterns, suggesting less optimal brushing and nutrition. This was linked to changed home routines and social presentability. Key informants described major disruptions in their oral health services and significant family fear and stress. In conclusion, the stay-at-home period of the COVID-19 pandemic was a time of extreme routine change and stress for families. Oral health interventions that target family routines and social presentability are important for families during times of extreme crisis.

Calibration and reliability testing of a novel asynchronous photographic plaque scoring system in young children

OBJECTIVES

The Simplified Oral Hygiene Index for Maxillary Incisors (OHI-MIS) is a novel plaque scoring system adapted for young children. This study describes calibration training and testing used to establish the inter- and intra-rater reliability for OHI-MIS measured from clinical photographs.

METHODS

Two raters from the Coordinated Oral Health Promotion Chicago (CO-OP) and one from the Behavioral EConomics for Oral health iNnovation (BEECON) randomized controlled trials (RCTs) underwent calibration with gold standard raters, followed by annual re-calibration. Raters from CO-OP also completed inter-rater reliability testing; all three raters completed intra-rater reliability testing rounds. Photographs were obtained from children aged 9-39 months.

RESULTS

All three raters achieved greater than 0.77 Lin's Concordance Correlation (LCC) versus gold standard consensus during calibration. All three raters had LCC ≥0.83 at recalibration 1 year later. CO-OP trial raters scored 604 photos (151 sets of 4 photographs); mostly both raters were somewhat/very confident in their scoring (≥89%), describing the most photos as "clear" (90% and 81%). The CO-OP inter-rater LCC for total OHI-MIS score was 0.86, changing little when low quality or confidence photos were removed. All three raters demonstrated high intra-rater reliability (≥0.83).

CONCLUSIONS

The OHI-MIS plaque scoring system on photos had good reliability within and between trials following protocol training and calibration. OHI-MIS provides a novel asynchronous plaque scoring system for use in young children. Non-clinicians in field or clinical settings can obtain photographs, offering new opportunities for research and clinical care.

Understanding the relationship between care team perceptions about CHWs and CHW integration within a US health system, a qualitative descriptive multiple embedded case study

BACKGROUND

Community health workers (CHW) have grown in prominence within the healthcare sector, yet there is no clear consensus regarding a CHW's role, purpose, and value within health systems. This lack of consensus has the potential to affect how CHWs are perceived, utilized, and ultimately integrated within the healthcare sector. This research examines clinical care teams that currently employ CHWs to (1) understand how members of the care team perceive CHWs' purpose and value, and (2) consider how perceptions of CHWs are related to CHW integration within health care teams.

METHODS

Researchers conducted a qualitative descriptive multiple embedded case study at the University of Illinois at Chicago's Hospital and Health Science System (UI Health). The embedded subunits of analysis were teams within UI Health that are currently employing CHWs to assist with the provision of clinical care or services to patients. Data were collected via semi-structured interviews and document review.

RESULTS

In total, 6 sub-units were enrolled to participate, and 17 interviews were conducted with CHWs (n = 9), and administrators or health care providers (n = 8). Reported perceptions of CHWs were inconsistent across respondents. CHWs roles were not always understood, and the CHW's purpose and value was perceived differently by different members of the care team. Moreover, evaluation metrics did not always capture CHWs' value to the health care system. In some cases, care teams were more aligned around a shared understanding of the CHW's roles and purpose within the care team. When perceptions regarding CHWs were both positive and aligned, respondents reported higher levels of integration within the healthcare system.

CONCLUSIONS

Alignment in a care team's perception of a CHW's role, purpose, and value within the health system could play an important role in the integration of CHWs within healthcare teams.

Improving Adherence in Urban Youth With Asthma: Role of Community Health Workers

BACKGROUND

The Asthma Action at Erie Trial is a comparative effectiveness trial comparing a community health worker (CHW) versus certified asthma educator (AE-C) intervention in low-income minority children.

OBJECTIVES

Determine whether asthma medication possession, adherence, technique, and triggers differ in children receiving an asthma CHW compared with an AE-C intervention.

METHODS

Children with uncontrolled asthma were randomized to receive 10 CHW home visits or 2 AE-C sessions in a clinic over 1 year. Asthma medication possession and inhaler technique were observed; adherence was measured using self-report, dose counters, and electronic monitors. Environmental triggers were captured by self-report, observation, and objective measurement. Mixed effects linear and logistic regression models were estimated for continuous and binary outcomes.

RESULTS

Children (n = 223) were mainly Hispanic (85%) and ages 5 to 16 years. Quick-relievers (82%), spacers (72%), and inhaled corticosteroid (ICS)-containing medications (44%) were tracked. Of those with uncontrolled asthma, 35% lacked an ICS prescription (n = 201). Children in the CHW arm were more likely to have an ICS prescription at 12 months (odds ratio 2.39; 95% CI 0.99-5.79). Inhaler technique improved 9.8% in the CHW arm at 6 months (95% CI 4.20-15.32). The ICS adherence improved in the CHW arm at 12 months, with a 16.0% (95% CI 2.3-29.7; P = .02) difference between arms. Differences in trigger exposure over time were not observed between arms.

CONCLUSIONS

The CHW services were associated with improved ICS adherence and inhaler technique, compared with AE-C services. More information is needed to determine the necessary dosage of intervention to sustain adherence.

Essential and non-essential US workers' health behaviors during the COVID-19 pandemic

We seek to quantify the relationship between health behaviors and work-related experiences during the COVID-19 pandemic by predicting health behaviors as a function of essential worker status, job loss, change in work hours, and COVID-19 experiences. We use multivariate models and survey data from 913 employed adults in a semi-rural mid-Atlantic US county, and test whether essential worker results vary by gender, parenthood, and/or university employment. Multivariate models indicate that essential workers used tobacco on more days (4.5; p <.01) and were less likely to sleep 8 h (odds ratio [OR] 0.6; p <.01) than non-essential workers. The risk of sleeping less than 8 h is concentrated among essential workers in the service industry (OR 0.5; p <.05) and non-parents (OR 0.5; p <.05). Feminine essential workers exercised on fewer days (-0.8; p <.05) than feminine non-essential workers. Workers with reduced work hours consumed more alcoholic drinks (0.3; p <.05), while workers with increased work hours consumed alcohol (0.3; p <.05) and exercised (0.6; p <.05) on more days. Essential worker status and changes in work hours are correlated with unhealthy behaviors during the COVID-19 pandemic.

Behind Closed Doors: A Thematic Analysis of Diabetes Community Health Worker Home Visit Content

The present work studies how community health workers (CHWs) perform the role of educator and how this relates to the implementation of other CHW roles, skills, and qualities. Prior studies on this topic have relied on interviews or focus groups rather than analysis of CHW interactions. We conducted a thematic analysis of 24 transcripts of conversations occurring between CHWs and participants during home visits as part of the Mexican American Trial of Community Health Workers, a randomized controlled trial that improved clinical outcomes among low-income Mexican American adults with type 2 diabetes. Three themes describing interactions related to diabetes self-management education accounted for about half of encounter content. The other half of encounter content was dedicated to interactions not explicitly related to diabetes described by 4 subthemes. In a successful CHW intervention, focused educational content was balanced with other interactions. Interactions not explicitly related to diabetes may have provided space for the implementation of core CHW roles, skills, and qualities other than educator, particularly those related to relationship building. It is important that interventions provide CHWs with sufficient time and flexibility to develop strong relationships with participants.

CHECK: Multi-level Real-World Pediatric Asthma Care Coordination: Results and Lessons Learned

OBJECTIVE

Because asthma health disparities in children remain common, innovative approaches to obtain asthma health equity are essential. Comprehensive care coordination programs may address the social determinants of health that influence these disparities. This analysis aims to ascertain if receipt of Coordination of Healthcare for Complex Kids (CHECK) program services was associated with changes in school absence, cost, healthcare utilization, and controller prescription in children with asthma.

METHODS

The CHECK program ran from December 1^st, 2014 through August 31^st, 2017. Engagement with Community Health Workers (CHW) was rolling and targeted based on risk level (low, medium or high determined by healthcare utilization). This analysis included school-aged children with asthma (n = 2,629) and sufficient Chicago Public Schools attendance data (n = 430).

RESULTS

Children engaged in CHECK were more likely to be female (p = 0.046) and to identify as Black and/or Hispanic/Latino than enrolled-only children. School absence was not different between the groups. Average total cost for engaged children was 21.3% more than enrolled-only children the first year (p = 0.027) but did not differ by the second year (p = 0.948). At baseline, 68.1% of the cohort had at least one ED visit 12-months prior to CHECK, this reduced to 49.5% post-1 and 41.9% post-2. Engaged children were 21% more likely to visit an ED (p = 0.010) and 40% more likely to have a controller.

CONCLUSIONS

CHECK program receipt was associated with reduced costs and improved healthcare utilization, and controller prescriptions. School attendance did not change. The CHECK model offers potential pathways to support low-income children with asthma.

Mixed-methods Analysis of Adults Likely versus Unlikely to Get a COVID-19 Vaccination

Objectives: This mixed-methods study compared perspectives of those 'very likely' versus 'very unlikely' to receive a hypothetical COVID-19 vaccine. Methods: We used an explanatory, sequential, mixed- methods design to analyze quantitative data from a rural Pennsylvania sample. Of the 976 participants, 67 selected 'very unlikely' to get the COVID-19 vaccine. Responses to open-ended questions: "What worries you the most about the COVID 19 pandemic?" and "What are your thoughts about a potential COVID 19 vaccine?" were qualitatively compared to answers from the 67 participants who selected 'very likely' to get the COVID-19 vaccine. We used descriptive content analysis to compare themes across the 2 groups. Results: Both groups had thematic commonalities related to their concerns. Themes that were more common among those 'very unlikely' to get vaccinated included concern for politics overriding vaccine safety and rushed vaccine development timeline, whereas themes related to hope and optimism about vaccination were exclusive to the 'very likely' group. Conclusions: Shared beliefs existed across groups with different intents to vaccinate; yet, identification with vaccine spokespersons differed. Messaging campaigns can use these commonalities to address vaccine hesitancy.

Oral community health worker-led interventions in households with average levels of psychosocial factors

Introduction

Household-level psychosocial stress levels have been linked to child tooth brushing behaviors. Community health worker (CHW) interventions that target psychosocial factors in high-risk communities have been associated with changes in health behaviors.

Aim

Observe changes in psychosocial factors over time and an association between psychosocial factors and CHW intervention dose amongst urban Chicago families.

Patients and methods

Participants (N = 420 families) were recruited from 10 community clinics and 10 Women, Infants, or Children (WIC) centers in Cook County, Illinois to participate in a clinical trial. Research staff collected participant-reported psychosocial factors (family functioning and caregiver reports of depression, anxiety, support, and social functioning) and characteristics of CHW-led oral health intervention visits (number, content, child engagement) at 0, 6, and 12 months. CHWs recorded field observations after home visits on household environment, social circumstances, stressors, and supports.

Results

Participants across the cohort reported levels of psychosocial factors consistent with average levels for the general population for nearly all measures. Psychosocial factors did not vary over time. Social functioning was the only measure reported at low levels [32.0 (6.9); 32.1 (6.7); 32.7 (6.9); mean = 50 (standard deviation)] at 0, 6, and 12 months. We did not observe a meaningful difference in social functioning scores over time by exposure to CHW-led intervention visits (control arm, 0, 1, 2, 3, and 4 visits). Field observations made by CHWs described a range of psychosocial stress related to poverty, language barriers, and immigration status.

Conclusion

The unexpectedly average and unchanging psychosocial factors over time, in the context of field observations of stress related to poverty, lack of support, immigration status, and language barriers, suggests that our study did not adequately capture the social determinants of health related to oral health behaviors or that measurement biases precluded accurate assessment. Future studies will assess psychosocial factors using a variety of instruments in an attempt to better measure psychosocial factors including social support, depression, anxiety, functioning, trauma and resilience within our urban population. We will also look at neighborhood-level factors of community distress and resilience to better apply the social ecologic model to child oral health behaviors.

Community health worker intervention to improve tooth brushing in young children: Results from a cluster randomized controlled trial

OBJECTIVES

Coordinated Oral health Promotion (CO-OP) Chicago is a cluster randomized controlled trial testing the efficacy of a community health worker (CHW) intervention to improve tooth brushing in low-income children.

METHODS

Four hundred twenty children under 3 years old (mean 21.5 months) were recruited from 20 sites in or near Chicago, IL. Children were identified mainly as Black race (41.9%) or Hispanic ethnicity (53.8%) and most (85.2%) had Medicaid. Intervention families were offered four CHW home visits over 1 year. Brushing frequency was self-reported. Plaque score was determined from images collected in homes using disclosing solution. Analyses used GEE logistic models with variable selection at p < .05.

RESULTS

At enrolment, 45.0% of families reported twice a day or more child brushing frequency, and child plaque scores were poor (mean of 1.9, SD: 0.6). Data were obtained from 87.1% of children at 6 months and 86.2% at 12 months. In the CHW intervention arm (10 sites, N = 211), 23.7% received 4 visits, 12.8% 3 visits, 21.3% 2 visits, 23.2% 1 visit and 19% no visits from CHWs. No intervention effect was seen for brushing frequency or plaque score. Child brushing frequency improvement over time was associated with a range of child and caregiver factors. The only factor associated with a change in plaque score over time was parent involvement in brushing.

CONCLUSIONS

Oral-health-specific CHW services were not associated with improved brushing behaviours in these young children. However, caregiver involvement with brushing supported more quality brushing. More robust interventions are needed to support families during this critical developmental period.

Rates of diagnoses of sleep disorders in children with chronic medical conditions

STUDY OBJECTIVES

This investigation examines sleep disorder (SD) diagnoses in a large population of children and adolescents with chronic medical conditions (CMCs). Little is known about SD diagnoses in this population. The large population used in this study allowed examination of SD rates by CMC type and demographics.

METHODS

Data were from the Coordinated Health Care for Complex Kids (CHECK) project designed for Medicaid-funded children and adolescents with at least one CMC from a large metropolitan area. The study population (N=16,609) was limited to children and adolescents, 0 to 18 years of age. SD and CMC diagnoses were obtained from Medicaid claims data.

RESULTS

Fourteen percent of the population (mean age of 9.1 years [SD= 5.2]; 35.8% African American (AA); 56.4% male; 77 with more than one CMC) received a sleep disorder diagnosis. The most frequent diagnosis was SDB (11.2%), followed by nocturnal enuresis (1.2%), and insomnia (1%). SDs were diagnosed more frequently in those with multiple CMCs than in those with one CMC (19.7% vs. 5.8%; p <0.001). Insomnia rates in Hispanic/Latinx (1.2%) and AA (0.8%) children and adolescents were significantly lower (both p<0.001) than in Caucasians (3.5%). Odds of receiving a sleep diagnosis varied among CMCs.

CONCLUSIONS

Our analysis of Medicaid claims data of a large urban cohort offers detailed information about the rates of sleep diagnoses and suggests under-diagnosis of SDs in this vulnerable, high-risk, primarily ethnic minority population. Under-recognition of sleep disorders have short- and long-term health and economic consequences. Study results may help clinicians implement appropriate SD screening and management for children and adolescents with CMCs.

The relative contributions of adiposity and activity levels to physical performance in children with excess weight

OBJECTIVE

This study examined predictors of physical performance, a key aspect of quality of life, in children with excess weight.

METHODS

Participants were 269 children aged 6-12 years with a body mass index above the 85th percentile. Children completed a standardized physical performance task capturing lower extremity strength, balance, and gait speed. Height, weight, and waist circumference were objectively measured, and daily moderate-vigorous physical activity (min/day) and sedentary time (% of day) were assessed with a 7-day accelerometer protocol.

RESULTS

Physical performance task completion averaged 15.0 (SD = 2.5) seconds. Children with higher body mass index z-scores and waist circumferences had significantly longer task completion times. The task took 1.8 additional seconds per 1.0 body mass index z-score (p < .001), and 1.2 additional seconds for every 20 cm higher waist circumference (p < .001). Daily moderate-vigorous physical activity and sedentary time were unrelated to physical performance, and did not moderate its associations with the adiposity measures.

CONCLUSION

Among children with excess weight, physical performance declines with increasing levels of total and central adiposity. Daily activity levels do not moderate this association. Interventions that directly target weight reduction would likely yield the greatest improvement in physical performance in children with overweight or obesity.

Attenuated efficacy of pediatric obesity treatment during the COVID-19 pandemic

OBJECTIVE

This study examined whether the efficacy of a standard-of-care pediatric obesity treatment was affected by the COVID-19 pandemic.

METHODS

Analyses leveraged data from an ongoing pediatric obesity treatment trial involving 230 lower-income, urban children aged 6 to 12 years. Mixed-effects regression models compared children who participated in a 12-month weight-management intervention before versus during the COVID-19 pandemic on change from baseline in BMI z score (ΔzBMI) at 3, 6, 9, and 12 months.

RESULTS

The observed pattern of ΔzBMI was significantly different before versus during the pandemic (χ² = 22.73, p < 0.0001). Children treated before the pandemic maintained an average weight loss of -0.06 ΔzBMI at 12 months, whereas children treated during the pandemic steadily gained weight over time, averaging a net gain of 0.11 ΔzBMI at 12 months (χ² = 34.99, p < 0.0001). Treatment session completion did not differ before versus during the pandemic (60.4% vs. 55.7%, respectively; p = 0.30) or account for differences in ΔzBMI.

CONCLUSIONS

Similar reductions in intervention efficacy may be anticipated in other pediatric obesity treatment trials conducted during the COVID-19 pandemic. Many families that have struggled with managing their child's weight during this period may need encouragement to continue engaging in structured weight management as society renormalizes.

Psychosocial Moderators and Outcomes of a Randomized Effectiveness Trial for Child Asthma

OBJECTIVE

Psychosocial factors play a role in child asthma morbidity and disparities, but their impact on asthma intervention effectiveness is less understood. This study examined how child, parent, and family psychosocial factors moderated asthma response to, and changed in response to, 2 community asthma interventions among urban minority youth.

METHODS

Asthma Action at Erie was a randomized comparative effectiveness trial examining a community health worker (CHW) home intervention versus certified asthma educator (AE-C) services for children aged 5-16 with uncontrolled asthma (N = 223; mean age = 9.37, SD = 3.02; 85.2% Hispanic). Asthma control was assessed via the Asthma Control Test (ACT)/childhood ACT and activity limitation. Baseline child/parent depression and posttraumatic stress disorder (PTSD) symptoms, family chaos, and social support were examined as treatment moderators. We also tested intervention effects on psychosocial outcomes.

RESULTS

For parents with higher baseline depression symptoms, youth in the CHW group had greater ACT improvement by 24 months (7.49 points) versus AE-C (4.76 points) and 51% reduction in days of limitation by 6 months versus AE-C (ß = -0.118; p = .0145). For higher parent PTSD symptoms, youth in CHW had 68% fewer days of limitation at 24 months versus AE-C (ß = -0.091; p = .0102). Psychosocial outcomes did not vary by group, but parent depression, parent and child PTSD symptoms, and social support improved for all.

CONCLUSIONS

CHW intervention was associated with improved asthma control among families with higher parent strain. Findings have implications for utilizing tailored CHW home interventions to optimize asthma outcomes in at-risk families.

Unique Predictors of Intended Uptake of a COVID-19 Vaccine in Adults Living in a Rural College Town in the United States

PURPOSE

To explore public confidence in a COVID-19 vaccine.

DESIGN

Cross-sectional survey.

SETTING

A rural college town in central Pennsylvania.

SUBJECTS

Adult residents without minor children.

MEASURES

The primary outcome was COVID-19 vaccination intention. Secondary measures included vaccination attitudes, norms, efficacy, past behavior, trust in the vaccination process, and sociodemographic variables of education, financial standing, political viewpoint, and religiosity.

ANALYSIS

Descriptive statistics were used to describe quantitative data. Multivariate ordinal regression was used to model predictors of vaccine intention.

RESULTS

Of 950 respondents, 55% were "very likely" and 20% "somewhat likely" to take a coronavirus vaccine, even though 70% had taken the flu vaccine since September 2019. The strongest predictors of vaccine acceptance were trust in the system evaluating vaccines and perceptions of local COVID-19 vaccination norms. The strongest predictors of negative vaccine intentions were worries about unknown side-effects and positive attitudes toward natural infection. Sociodemographic factors, political views, and religiosity did not predict vaccine intentions.

CONCLUSION

Fewer adults intend to take a coronavirus vaccine than currently take the flu vaccine. Traditional sociodemographic factors may not be effective predictors of COVID-19 vaccine uptake. Although based on a small sample, the study adds to our limited understanding of COVID-19-specific vaccine confidence among some rural Americans and suggests that traditional public health vaccination campaigns based on sociodemographic characteristics may not be effective.

COVID-19 Impact on Community-Based Participatory Randomized Controlled Trials—Lessons From the Oral Health Disparities in Children Consortium

The COVID-19 pandemic has had a major impact on nearly every sector of science and industry worldwide, including a significant disruption to clinical trials and dentistry. From the beginning of the pandemic, dental care was considered high risk for viral transmission due to frequent aerosol-generating procedures. This resulted in special challenges for dental providers, oral health care workers, patients, and oral health researchers. By describing the effect that the COVID-19 pandemic had on four community-based randomized clinical trials in the Oral Health Disparities in Children (OHDC) Consortium, we highlight major challenges so researchers can anticipate impacts from any future disruptions.

Community Health Worker Asthma Interventions for Children: Results From a Clinically Integrated Randomized Comparative Effectiveness Trial (2016‒2019)

Objectives. To compare asthma control for children receiving either community health worker (CHW) or certified asthma educator (AE-C) services. Methods. The Asthma Action at Erie Trial is a comparative effectiveness trial that ran from 2016 to 2019 in Cook County, Illinois. Participants (aged 5‒16 years with uncontrolled asthma) were randomized to 10 home visits from clinically integrated asthma CHWs or 2 in-clinic sessions from an AE-C. Results. Participants (n = 223) were mainly Hispanic (85%) and low-income. Both intervention groups showed significant improvement in asthma control scores over time. Asthma control was maintained after interventions ended. The CHW group experienced a greater improvement in asthma control scores. One year after intervention cessation, the CHW group had a 42% reduction in days of activity limitation relative to the AE-C group (b = 0.58; 95% confidence interval = 0.35, 0.96). Conclusions. Both interventions were associated with meaningful improvements in asthma control. Improvements continued for 1 year after intervention cessation and were stronger with the CHW intervention. Public Health Implications. Clinically integrated asthma CHW and AE-C services that do not provide home environmental remediation equipment may improve and sustain asthma control.

Exploring Behavioral Typologies to Inform COVID-19 Health Campaigns: A Person-Centered Approach

As the United States continues to be ravaged by COVID-19, it becomes increasingly important to implement effective public health campaigns to improve personal behaviors that help control the spread of the virus. To design effective campaigns, research is needed to understand the current mitigation intentions of the general public, diversity in those intentions, and theoretical predictors of them. COVID-19 campaigns will be particularly challenging because mitigation involves myriad, diverse behaviors. This study takes a person-centered approach to investigate data from a survey (N = 976) of Pennsylvania adults. Latent class analysis revealed five classes of mitigation: one marked by complete adherence with health recommendations (34% of the sample), one by complete refusal (9% of the sample), and three by a mixture of adherence and refusal. Statistically significant covariates of class membership included relatively positive injunctive norms, risk due to essential workers in the household, personal knowledge of someone who became infected with COVID-19, and belief that COVID-19 was a leaked biological weapon. Additionally, trait reactance was associated with non-adherence while health mavenism was associated with adherence. These findings may be used to good effect by local healthcare providers and institutions, and also inform broader policy-making decisions regarding public health campaigns to mitigate COVID-19.

Trends in School Attendance for Low-Income Children with Chronic Health Conditions: Results from a Randomized Controlled Trial

BACKGROUND

In this study, we aimed to determine how school attendance changed over time for children on Medicaid with chronic health conditions enrolled in a comprehensive care coordination program called Coordinated HEalthcare for Complex Kids (CHECK).

METHODS

Medicaid beneficiaries from one managed care organization were randomized into 2 arms: CHECK program services or usual care. The final sample was 1322.

RESULTS

The mean age was 10.9 (SD = 3.7) years old and children were mostly non-Hispanic Black (62.6%) or Hispanic (34.9%). The median school attendance at baseline was 94.9% (IQR 88.9, 97.9); over one-fourth of children (28.4%) were chronically absent. School attendance was not associated with race/ethnicity, risk level, and health condition. In a model including a significant time/grade interaction, school attendance increased over time for children in pre-kindergarten (OR = 1.52, 95% CI: 1.38, 1.68; p < .001) and kindergarten to 5th grade (OR = 1.21, 95% CI: 1.17, 1.26; p < .001), and decreased for children in 6th to 8th grade (OR = 0.80, 95% CI: 0.77, 0.83; p < .001). No differences were seen in school attendance or chronic absenteeism associated with enrollment in the CHECK program.

CONCLUSIONS

School attendance improved for most of the low-income children with chronic health conditions in our cohort, except for children in middle school.

What is the causal effect of income gains on youth obesity? Leveraging the economic boom created by the Marcellus Shale development

Low family income is frequently assumed to be a primary social determinant of youth obesity in the U.S. But while the observed correlation between family income and youth obesity is consistently negative, the true causal relationship is unclear. I take advantage of a natural experiment - the boom economy created by development of the Marcellus Shale geological formation for natural gas extraction - to study whether income gains affect youth obesity rates among Pennsylvania students. To test this relationship, I compile data from geological, administrative, Census and other governmental sources and estimate cross-sectional OLS regression models, longitudinal fixed effects models, and two-stage instrumental variable models within a difference-in-differences framework. Falsification tests indicate that children's location relative to the Marcellus Shale's geological boundaries is a valid instrument for income gains. Yet plausibly exogenous income gains do not alter youth obesity rates, regardless of the community's initial level of poverty or affluence and regardless of the child's grade level. Thus, the observed disparities in youth obesity by area income in Pennsylvania do not result from simple differences in disposable income and the relative cost of "healthy" versus "unhealthy" goods and services.

Are Feminine Body Weight Norms Different for Black Students or in Black Schools? Girls' Weight-Related Peer Acceptance across Racialized School Contexts

Adolescent girls with overweight or obesity are less socially integrated than their thinner peers. We examine racial-ethnic differences in girls' weight-related friendship patterns, especially noting Black-white distinctions given their different norms about the ideal feminine form. We also test whether schools with more Black students see diminished weight-related differences in peer integration for all girls and/or for Black girls. Using 1994-1995 data from the National Longitudinal Study of Adolescent to Adult Health, we predict the number of friendship nominations girls receive conditional on their weight status, race-ethnicity, and school's racial composition. Both white and Black girls with overweight or obesity are less integrated than their thinner peers regardless of the school's Black enrollment rate. Hispanic girls with overweight are more integrated than white girls with overweight, particularly in schools with low Black enrollments. The relative consistency of girls' weight-related friendship patterns demonstrates the ubiquity of dominant feminine thinness norms.

Design and sample characteristics of COordinated Oral health Promotion (CO-OP) Chicago: A cluster-randomized controlled trial

COordinated Oral health Promotion (CO-OP) Chicago is a two-arm cluster-randomized trial with a wait-list control. The primary aim is to evaluate the efficacy of an oral health community health worker (CHW) intervention to improve oral health behaviors in low-income, urban children under the age of three years. Exploratory aims will determine cost-effectiveness, and if any CHW intervention impact on child tooth brushing behaviors varies when CHWs are based out of a medical clinic compared to a community setting. This paper describes progress toward achieving these aims. Participating families were recruited from community social service centers and pediatric primary care medical clinics in Cook County, Illinois. Sites were cluster-randomized to CHW intervention or usual services (a wait-list control). The intervention is oral health support from CHWs delivered in four visits to individual families over one year. The trial sample consists of 420 child/caregiver dyads enrolled at the 20 participating sites over 11 months. Participant demographics varied across the sites, but primary outcomes values at baseline did not. Data on brushing frequency, plaque, and other oral health behaviors are collected at three timepoints: baseline, 6-, and 12-months. The primary analysis will assess differences in caregiver-reported child brushing frequency and observed plaque score between the two arms at 12-months. The trial is currently in the active intervention phase. The trial's cluster-randomized controlled design takes a real-world approach by integrating into existing health and social service agencies and collecting data in participant homes. Results will address an important child health disparity. ClinicalTrials.gov identifier: NCT03397589. CLINICAL TRIAL REGISTRATION: University of Illinois at Chicago Protocol Record 2017-1090. National Institutes of Dental & Craniofacial Research of the National Institutes of Health (NIDCR) Protocol Number: 17-074-E. NCT03397589.

Implementation Lessons From a Randomized Trial Integrating Community Asthma Education for Children

This study characterized and compared the implementation of clinically integrated community health workers (CHWs) to a certified asthma educator (AE-C) for low-income children with asthma. In the AE-C arm (N = 115), 51.3% completed at least one in-clinic education session. In the CHW arm (N = 108), 722 home visits were completed. The median number of visits was 7 (range, 0-17). Scheduled in-clinic asthma education may not be the optimal intervention for this patient population. CHW visit completion rates suggest that the schedule, location, and content of CHW asthma services better met patients' needs. Seven to 10 visits seemed to be the preferred CHW dose.

Can an Instrument Validated to Assess Parent-Child Interactions in the Laboratory Setting Be Applied to Home-Based Observations?

Background: The Toothbrushing Observations Scale (TBOS) was developed in a laboratory setting to measure child and parent behaviors during toothbrushing. However, we required an instrument to assess home based behaviors. We assessed the feasibility of applying TBOS to observations of parents and their child (<3 years of age) in urban homes. Methods: Sample consisted of 36 families recruited from university and community pediatric dental/medical clinics and a Women, Infants, and Children center in Chicago as part of a pilot study for a larger clinical trial. The average age of children in our sample was 20.7 months. Most of the parent participants were mothers (90%), and 75% of the parents identified as Hispanic. Parent-child dyads were video-recorded during home-based toothbrushing activities and footage was reviewed by two independent TBOS coders. Results: The TBOS instrument consists of 12 parent and 18 child items. We were able to code five parent and ten child items. Conclusion: The feasibility of applying the TBOS measure to our study population was somewhat limited by factors related to home-based observations and the young age of children in our study. Instruments need to be validated across natural settings, such as the home, to increase the quality and accuracy of human behavioral data.

Parent Nativity and Child Asthma Control in Families of Mexican Heritage: The Effects of Parent Depression and Social Support

OBJECTIVE

Research has repeatedly demonstrated that parent foreign nativity has a protective effect on child asthma outcomes among Mexican Americans, but the mechanisms underlying this relationship are not well understood. The current study explored parent depression as a mediator and social support as a moderator of the parent nativity-child asthma control pathway.

METHODS

Data come from the baseline sample of a trial (NCT02481986) testing community interventions for 223 children aged 5 to 16 with uncontrolled asthma. We focused on parent/child dyads of Mexican heritage (N = 165; mean age = 9.08, standard deviation = 2.94; 57.3% with Mexico-born parent). Asthma control was defined using the child and adult versions of the Asthma Control Test (ACT). Psychosocial factors included parent depression symptoms and social (instrumental, informational, and emotional) support.

RESULTS

Mexican-born parents had fewer depressive symptoms (β^ = -2.03, SE^ = 0.24) and children with better asthma control (β^ = 1.78, SE^ = 0.24) than US-born parents, P < .0001. Analyses suggested partial mediation of the nativity-ACT path via parent depression (P < .001). An interaction between Instrumental Support and Nativity was marginally significant (β^ = -0.10, SE^ = 0.05, P = .07), with protective effects only observed at higher support levels. Last, among Mexico-born parents, the protective nativity effects on ACT declined with increasing residential years in the United States through 12 years.

CONCLUSIONS

This study is novel in identifying parent depression as one mechanism underlying the effects of parent nativity on child asthma control, but results suggest that the health advantages may depend on availability of support. Providing resources for parent depression and instrumental support (transportation, childcare) can optimize asthma interventions in this population.

Family Chaos and Asthma Control

OBJECTIVES

Asthma is a highly prevalent childhood chronic disease, with particularly high rates among poor and minority youth. Psychosocial factors have been linked to asthma severity but remain poorly understood. This study examined (1) relationships between parent and child depression and posttraumatic stress disorder (PTSD) symptoms, family functioning, and child asthma control in a sample of urban minority youth with uncontrolled asthma and (2) family functioning as a pathway linking parent depression and asthma outcomes.

METHODS

Data were drawn from the baseline cohort of a randomized trial testing community interventions for children aged 5 to 16 with uncontrolled asthma (N = 223; mean age = 9.37, SD = 3.02; 85.2% Hispanic). Asthma control was defined by using the Asthma Control Test and Childhood Asthma Control Test, activity limitation, and previous-12-month asthma severity. Psychosocial measures included parent and child depression and PTSD symptoms, family chaos, and parent social support.

RESULTS

Parent and child depression symptoms, but not PTSD, were associated with worse asthma control (β = -.20 [SE = 0.06] and β = -.12 [SE = -.03]; P < .001). Family chaos corresponded to worse asthma control, even when controlling for parent and child depression (β = -.33; [SE = 0.15]; P < .05), and was a mediator of the parent depression-asthma path. Emotional triggers of asthma also mediated the parent depression-asthma relationship.

CONCLUSIONS

Findings highlight family chaos as a mechanism underlying the relationship between parent depression and child asthma control. Addressing parent and child depression, family routines, and predictability may optimize asthma outcomes.

A multivariable analysis of childhood psychosocial behaviour and household functionality

BACKGROUND

Social determinants of health play a vital role in population health. Awareness of household social factors and their impact on health can help health professionals to provide effective strategies in health promotion, especially for children and adolescents showing signs of psychosocial dysfunction. The objective of this study was to explore the association between parents' perceptions of the psychosocial behaviour of their children and the functionality of their household.

METHODS

This cohort study analysed data from the Coordinated Health Care for Complex Kids programme. The sample included 293 parents of children aged 4-17 years with chronic conditions, and from urban, low-income families. Psychosocial behaviour of the child was measured using the Pediatric Symptom Checklist (PSC-17), which included subscales for internal, external, and attention symptoms. Household functionality was measured using the Confusion, Hubbub, and Order Scale. Responses to both assessments were scored in a standard manner.

RESULTS

There was a significant association between parents' perceptions of the psychosocial behaviour of their children and the functionality of the home environment. The mean Confusion, Hubbub, and Order Scale scores in the home environment improved from baseline to the first reassessment (the period between the two assessments ranged from 4 to 8 months). Additionally, positive PSC-17 screening results of the children decreased by 11% in the first reassessment. The odds of having a positive PSC-17 screening result also decreased in the first reassessment after receiving interventions.

CONCLUSION

The association between psychosocial dysfunction and household functionality indicates the importance of family-centred care and taking the home environment into consideration when administering health services to low-income children with chronic conditions. This study brings attention to the more hidden factors that influence child mental health, which must be addressed to improve care delivery and child health outcomes.

Design and baseline characteristics of a low-income urban cohort of children with asthma: The Asthma Action at Erie Trial

OBJECTIVE

To describe the methodology of a randomized controlled trial comparing the efficacy of integrated asthma community health workers (CHW) and a certified asthma educator (AE-C) to improve asthma outcomes in low-income minority children in Chicago.

METHODS

Child/caregiver dyads were randomized to CHW home visits or education in the clinic from an AE-C. Intervention was delivered in the first year after enrollment. Data collection occured at baseline, 6-, 12-, 18, and 24-months. The co-primary outcomes included asthma control using the Asthma Control Test/childhood Asthma Control Test (ACT/cACT) and activity limitation over the past 14 days.

RESULTS

A total of 223 participants ages 5-16 years were randomized. The majority of children were in the 5-11 year old range (78.9%). Most caregivers (96.9%) and 44% of children were female. Approximately 85% of caregivers and children reported Hispanic ethnicity and 62.3% reported a household income of ≤ $59,000. Over half (55.7%) had uncontrolled asthma as measured by ACT/cACT; 13.9% had a normal ACT/cACT score but were uncontrolled using the Asthma Control Questionnaire and 20.2% were controlled on both measures but had received oral steroids in the past year for asthma.

CONCLUSION

The Asthma Action at Erie Trial successfully recruited a largely Hispanic cohort of children with uncontrolled or high-risk asthma to study the differential effects of clinic-based AE-C and home-based CHW interventions. Strengths of the trial include its comparative effectivness design that integrates interventionists and intervention delivery into a clinical setting. Categorizing asthma control in community settings for research purposes presents unique challenges.

CLINICAL TRIAL REGISTRATION

University of Illinois at Chicago Protocol Record R01HL123797, Asthma Action at Erie TrialClinicalTrials.gov Identifier: NCT02481986 "ClinicalTrials.gov Registration" register@clinicaltrials.gov.

Chicago Public School nurses examine barriers to school asthma care coordination

OBJECTIVE/DESIGN

Well documented asthma disparities in Chicago pose a continual challenge for the Chicago Public Schools (CPS). Coordinated Healthcare for Complex Kids (CHECK) is a health care demonstration project funded by a Centers for Medicare and Medicaid Services Health Care Innovation Award. A collaborative partnership was formed between CHECK and CPS. With CHECK support, CPS administered a survey to 160 nurses to understand the asthma problems nurses perceived and interest in intervention.

RESULTS

Seventy-five per cent (n = 120) completed the survey. While asthma was the top diagnosis managed by 95%, 72% reported gaps in asthma understanding. Appropriate communication between school nurses and providers occurred 33% of the time; 18% believed they received sufficient support to follow-up on deficient paperwork. The barriers mentioned were lack of medications (73%), time (67%), and communication with providers (61%). When asked their opinions on potential interventions, 78% of nurses supported web-based applications, 66% community health workers (CHW), and 66% stock albuterol in schools.

CONCLUSIONS

The greatest barriers for CPS nurses with asthma management are time and communication. Potential interventions such as web-based communication applications and CHW in schools were well received.

Childhood Asthma Disparities in Chicago: Developing Approaches to Health Inequities

We conducted a needs assessment to develop an evidence-based, locally tailored asthma care implementation plan for high-risk children with asthma in Chicago. Our team of health policy experts, clinicians, researchers, and designers included extensive stakeholder engagement (N = 162) in a mixed-methods community needs assessment. Results showed the lines of communication and collaboration across sectors were weak; caregivers were the only consistent force and could not always manage this burden. A series of recommendations for interventions and how to implement and measure them were generated. Cooperative, multidisciplinary efforts grounded in the community can target wicked problems such as asthma.

Dietary Assimilation among Mexican Children in Immigrant Households: Code-switching and Healthy Eating across Social Institutions

Immigrant health assimilation is often framed as a linear, individualistic process. Yet new assimilation theory and structural theories of health behavior imply variation in health assimilation as immigrants and their families interact with different US social institutions throughout the day. We test this idea by analyzing how two indicators of dietary assimilation-food acculturation and healthy eating-vary throughout the day as Mexican children in immigrant households consume food in different institutional settings. Using individual fixed-effects models and data from the National Health and Nutrition Examination Survey, we find that Mexican children in immigrant households (N = 2,337) engage in "dietary code-switching," eating more acculturated but not necessarily less healthy food in schools and more acculturated but less healthy food in restaurants compared to homes. Findings advance theory and knowledge about how social institutions condition dietary assimilation in particular and health assimilation more broadly.

The Role of Time Use Behaviors in the Risk of Obesity among Low-Income Mothers

OBJECTIVES

Childrearing responsibilities create additional demands on women's time and effort, especially in low-income families. We explore whether childrearing demands and differences in time use increase the risk of overweight and obesity for women in different income brackets.

METHODS

We use data for women ages 18-55 years from the 2006-2008 and 2014-2015 American Time Use Surveys (N = 17,914). We predict whether women engage in particular activities using logistic regression and, among those who do particular activities, we predict the minutes spent in various activities using ordinary least squares models. We also predict women's risk of overweight or obesity using logistic regression. All models examine conditional relationships between income level and motherhood status.

RESULTS

Replicating prior research, we find a greater risk of overweight and obesity for mothers with low (odds ratio, 1.66; p < .001) and subpoverty (odds ratio, 1.93; p < .001) incomes compared with mothers with moderate/upper incomes and all child-free women. Motherhood and income status jointly predict women's time use, but including these time use behaviors in models of overweight and obesity does not attenuate the significantly higher risks for mothers with low and subpoverty incomes.

CONCLUSIONS

Mothers experiencing economic hardship are at greater risk of overweight and obesity relative to other women. Additional research is warranted, however, because differences in time use do not explain this important health disparity.

Formative research implications on design of a randomized controlled trial for oral health promotion in children

BACKGROUND

The COordinated Oral health Promotion (CO-OP) Chicago trial will test the efficacy of a community health worker (CHW) intervention to improve oral health behaviors for children at high risk for early childhood caries. Before implementing the cluster-randomized controlled trial, we conducted a formative assessment to determine the final design. We used qualitative methods to assess the feasibility and acceptability of the proposed recruitment, data collection, and intervention plan.

METHODS

Key informant interviews (N = 37) and site observations were conducted at 10 pediatric primary care clinics and 10 Special Supplemental Nutrition Program for Women Infant and Children (WIC) centers to gain insight from providers and administrators at the locations where recruitment and intervention will occur. Eight focus groups (N = 68) were conducted with caregivers of children to capture the parent perspective. Conceptual coding methods from grounded theory were applied to organize the data into the final themes.

RESULTS

Families, clinics, and WIC centers were all very interested in additional supports for oral health and were enthusiastic about CHWs. Challenges included competing family priorities that might interfere in study enrollment and intervention efficacy. Physical space for enrollment and intervention delivery was a major barrier for some sites. Home visits for data collection and intervention delivery would be unacceptable for some families. These challenges and barriers prompted us to make major changes in our trial design. We opened the option for data collection to occur in multiple locations. We eliminated the home-only arm of the trial. Clinics and WIC centers that are randomized to the non-intervention arm will now have CHWs available at the study conclusion. Finally, we aligned the CHW oral health topics to the needs of families.

CONCLUSIONS

We conducted this comprehensive formative assessment to determine the feasibility and acceptability of the CO-OP Chicago trial. While overall acceptance of the trial was high, the results highlighted specific issues with the proposed trial implementation plan and led to several critical design changes. This type of formative work requires a significant upfront investment but we expect it will translate into savings through better recruitment, retention, intervention implementation and adherence, and result dissemination.

Oral Health Problems and Solutions in High-Risk Children and Young Adults

Purpose: The Coordinated Healthcare for Complex Kids (CHECK) project targets publically insured children and young adults with chronic diseases. The CHECK oral health program intervenes at individual, family, and community levels. This paper describes the baseline oral health status of CHECK patients. Methods: CHECK patients older than 18 years of age and caretakers of younger patients were asked about their oral health. Medicaid claims data were used to determine diagnoses and level of risk. Attendance data from the Chicago Public Schools was obtained to assess absenteeism. Results: Of the 5,509 CHECK patients, 1,122 (20.4%) reported some type of oral health problem in the last six months. The most common issue was a history of dental caries (<small>N</small>=753, 13.7%). The odds of oral health problems increased significantly in adolescents (odds ratio [OR]=1.20; 95% confidence interval [CI]=1.02 to 1.40) and young adults (OR=1.55; 95% CI=1.31 to 1.85) compared with children. Males were less likely than females to have oral health problems (OR=0.83, 95% CI=0.73 to 0.95). Worse general health was significantly associated with oral health problems. Conclusion: CHECK is implementing a multilevel comprehensive approach to address oral health problems.