http://pediatrics.aappublications.org:80 This feed contains articles for Pediatrics Subject Collection "Office Practice" Pediatrics http://pediatrics.aappublications.org:80 http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S161?rss=1 Demographic changes in the United States bring diverse cultures, languages, and challenges to health care delivery, particularly for children. Providing high-quality health care that is patient centered and equitable requires tailored care and a focus on both health care disparities and health literacy.1 Major connections between health literacy and disparities include a common focus on improving quality of care, improving patient-provider communication, overcoming language barriers, understanding the health beliefs of patients, and a need for pediatric-focused research. Reports by the Institute of Medicine have highlighted health-disparity reduction and health-literacy improvement as critical components for high-quality health and health care for Americans.1-5 Although ... Cheng, T. L. Dreyer, B. P. Jenkins, R. R. 2009-11-01 doi:10.1542/peds.2009-1100C Introduction: Child Health Disparities and Health Literacy American Academy of Pediatrics SUPPLEMENT_3 124 162 161 2009-11-01 SUPPLEMENT ARTICLES http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S163?rss=1 In this article we argue for the utility of the life-course perspective as a tool for understanding and addressing health disparities across socioeconomic and racial or ethnic groups, particularly disparities that originate in childhood. Key concepts and terms used in life-course research are briefly defined; as resources, examples of existing literature and the outcomes covered are provided along with examples of longitudinal databases that have often been used for life-course research. The life-course perspective focuses on understanding how early-life experiences can shape health across an entire lifetime and potentially across generations; it systematically directs attention to the role of context, including social and physical context along with biological factors, over time. This approach is particularly relevant to understanding and addressing health disparities, because social and physical contextual factors underlie socioeconomic and racial/ethnic disparities in health. A major focus of life-course epidemiology has been to understand how early-life experiences (particularly experiences related to economic adversity and the social disadvantages that often accompany it) shape adult health, particularly adult chronic disease and its risk factors and consequences. The strong life-course influences on adult health could provide a powerful rationale for policies at all levels--federal, state, and local--to give more priority to investment in improving the living conditions of children as a strategy for improving health and reducing health disparities across the entire life course. Braveman, P. Barclay, C. 2009-11-01 doi:10.1542/peds.2009-1100D Health Disparities Beginning in Childhood: A Life-Course Perspective American Academy of Pediatrics SUPPLEMENT_3 124 175 163 2009-11-01 SUPPLEMENT ARTICLES http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S176?rss=1 A child's sense of control over life and health outcomes as well as perceptions of the world as fair, equal, and just are significantly influenced by his or her social experiences and environment. Unfortunately, the social environment for many children of color includes personal and family experiences of racial discrimination that foster perceptions of powerlessness, inequality, and injustice. In turn, these perceptions may influence child health outcomes and disparities by affecting biological functioning (eg, cardiovascular and immune function) and the quality of the parent-child relationship and promoting psychological distress (eg, self-efficacy, depression, anger) that can be associated with risk-taking and unhealthy behaviors. In this article we review existing theoretical models and empirical studies of the impact of racial discrimination on the health and development of children of color in the United States. On the basis of this literature, a conceptual model of exposure to racial discrimination as a chronic stressor and a risk factor for poor health outcomes and child health disparities is presented. Sanders-Phillips, K. Settles-Reaves, B. Walker, D. Brownlow, J. 2009-11-01 doi:10.1542/peds.2009-1100E Social Inequality and Racial Discrimination: Risk Factors for Health Disparities in Children of Color American Academy of Pediatrics SUPPLEMENT_3 124 186 176 2009-11-01 SUPPLEMENT ARTICLES http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S187?rss=1 Children in immigrant families now comprise 1 in 5 children in the United States. Eighty percent of them are US citizens, and 53% live in mixed-citizenship families. Their families are among the poorest, least educated, least insured, and least able to access health care. Nonetheless, these children demonstrate better-than-expected health status, a finding termed "the immigrant paradox" and one suggesting that cultural health behaviors among immigrant families might be protective in some areas of health. In this article the strength of the immigrant paradox, the effect of acculturation on health, and the relationships of acculturation, enculturation, language, and literacy skills to health disparities are reviewed. The current public policy issues that affect the health disparities of children of immigrant families are presented, and a research agenda for improving our knowledge about children in immigrant families to develop effective interventions and public policies that will reduce their health disparities is set forth. Mendoza, F. S. 2009-11-01 doi:10.1542/peds.2009-1100F Health Disparities and Children in Immigrant Families: A Research Agenda American Academy of Pediatrics SUPPLEMENT_3 124 195 187 2009-11-01 SUPPLEMENT ARTICLES http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S196?rss=1 Biological, psychological, and social processes interact over a lifetime to influence health and vulnerability to disease. Those interested in studying and understanding how and why racial/ethnic and social disparities emerge need to focus on the intersection of these processes. Recent work exploring molecular epigenetic mechanisms of gene expression (in humans as well and other mammalian systems) has provided evidence demonstrating that the genome is subject to regulation by surrounding contexts (eg, cytoplasmic, cellular, organismic, social). The developing stress axis is exquisitely sensitive to regulation by social forces represented at the level of the epigenome. Old assumptions about an inert genome are simply incorrect. Epigenetic processes may provide the missing link that will allow us to understand how social and political conditions, along with individual subjective experiences, can directly alter gene expression and thereby contribute to observed social inequalities in health. Developmental neurogenomics may provide the direct link between the biological and social/psychological worlds. These biological mechanisms of plasticity (at the level of gene expression and regulation) may play a profound role in how we conceptualize health inequalities by informing our concepts regarding the somatization or embodiment of social inequalities. Francis, D. D. 2009-11-01 doi:10.1542/peds.2009-1100G Conceptualizing Child Health Disparities: A Role for Developmental Neurogenomics American Academy of Pediatrics SUPPLEMENT_3 124 202 196 2009-11-01 SUPPLEMENT ARTICLES http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S212?rss=1 Overall, the excellent set of articles in this supplement to Pediatrics1-5 defines the critical issues for exploring the life-course perspective on child health disparities and identifies many of the important relationships between social stratification, race/ethnicity, environment, biology, and "time," that is, over the life course. The purpose of this commentary is to call attention to some of the outstanding challenges (to both science and policy) of adopting this life-course perspective that are raised by the authors. Specifically, we will focus briefly on (1) attributable risk, (2) the gradient effect, (3) biological processes, and (4) policy implications. ATTRIBUTABLE RISK ATTRIBUTABLE RISK THE GRADIENT BIOLOGICAL PROCESSES ... Guyer, B. Ma, S. 2009-11-01 doi:10.1542/peds.2009-1100I Conceptualizing Health Disparities: Panel Reflections American Academy of Pediatrics SUPPLEMENT_3 124 213 212 2009-11-01 SUPPLEMENT ARTICLES http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S214?rss=1 Despite an accumulating body of literature addressing racial/ethnic disparities in children's health and health care, there have been few published studies of interventions that have been successful in eliminating these disparities. The objectives of this article, therefore, are to (1) describe 3 interventions that have been successful in eliminating racial/ethnic disparities in children's health and health care, (2) highlight tips and pitfalls regarding devising, implementing, and evaluating pediatric disparities interventions, and (3) propose a research agenda for pediatric disparities interventions. Key characteristics of the 3 successful interventions include rigorous study designs; large sample sizes; appropriate comparison groups; community-based interventions that are culturally and linguistically sensitive and involve collaboration with participants; research staff from the same community as the participants; appropriate blinding of outcomes assessors; and statistical adjustment of outcomes for relevant covariates. On the basis of these characteristics, I propose tips, pitfalls, an approach, and a research agenda for devising, implementing, and evaluating successful pediatric disparities interventions. Examination of 3 successful interventions indicates that pediatric health care disparities can be eliminated. Achievement of this goal requires an intervention that is rigorous, evidence-based, and culturally and linguistically appropriate. The intervention must also include community collaboration, minimize attrition, adjust for potential confounders, and incorporate mechanisms for sustainability. Flores, G. 2009-11-01 doi:10.1542/peds.2009-1100J Devising, Implementing, and Evaluating Interventions to Eliminate Health Care Disparities in Minority Children American Academy of Pediatrics SUPPLEMENT_3 124 223 214 2009-11-01 SUPPLEMENT ARTICLES http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S224?rss=1 Relatively few quality-improvement efforts have been aimed at reducing differences in children's care and outcomes across race and ethnicity, socioeconomic status, and insurance status. To inform quality-improvement efforts to reduce child health disparities, we summarize lessons learned from the adult disparities-intervention literature, identify interventions that have reduced disparities in pediatric asthma outcomes and immunization rates, and outline special considerations for child disparity interventions. Key recommendations for providers, health care organizations, and researchers include: (1) examine your performance data stratified according to insurance status, race/ethnicity, language, and socioeconomic status; (2) measure and improve childhood health-related quality of life, development, and condition-specific targets (such as asthma and immunizations); (3) measure and improve anticipatory guidance for early prevention of conditions (such as injuries, violence, substance abuse, and sexually transmitted diseases) and efforts to promote positive growth (such as readership programs to improve low literacy); (4) measure and improve structural aspects of care that affect child health outcomes and can reduce disparities, such as patient-centered medical-home elements; (5) incorporate families into interventions; (6) use multidisciplinary teams with close tracking and follow-up of patients; (7) integrate non-health care partners into quality-improvement interventions; and (8) culturally tailor quality improvement. A key recommendation for payers is to align financial incentives to reduce disparities. The National Institutes of Health and other funders should support (1) disparity-intervention studies on these recommendations that analyze clinical outcomes, intervention-implementation processes, and costs, and (2) creation of new child health services researchers who can find effective quality-improvement approaches for reducing disparities. Chin, M. H. Alexander-Young, M. Burnet, D. L. 2009-11-01 doi:10.1542/peds.2009-1100K Health Care Quality-Improvement Approaches to Reducing Child Health Disparities American Academy of Pediatrics SUPPLEMENT_3 124 236 224 2009-11-01 SUPPLEMENT ARTICLES http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S237?rss=1 National attention to racial and ethnic health disparities has increased over the last decades, but marked improvements in minority health, especially among children, have been slow to emerge. A life-course perspective with sustained community engagement takes into account root causes of poor health in minority and low-income communities. This perspective involves a variety of primary care, public health, and academic stakeholders. A life-course perspective holds great promise for having a positive impact on health inequities. In this article we provide background information on available tools and resources for engaging with communities. We also offer examples of community-primary care provider interventions that have had a positive impact on racial and ethnic health disparities. Common elements of these projects are described; additional local and national resources are listed; and future research needs, specifically in communities around issues that are relevant to children, are articulated. Examples throughout the history of pediatrics show the potential to eliminate racial and ethnic health disparities not only for children but also for all populations across the life course. Ochoa, E. R. Nash, C. 2009-11-01 doi:10.1542/peds.2009-1100L Community Engagement and its Impact on Child Health Disparities: Building Blocks, Examples, and Resources American Academy of Pediatrics SUPPLEMENT_3 124 245 237 2009-11-01 SUPPLEMENT ARTICLES http://pediatrics.aappublications.org:80/cgi/content/short/124/Supplement_3/S246?rss=1 A full accounting of the excess burden of poor health in childhood must include any continuing loss of productivity over the life course. Including these costs results in a much higher estimate of the burden than focusing only on medical costs and other shorter-run costs to parents (such as lost work time). Policies designed to reduce this burden must go beyond increasing eligibility for health insurance, because disparities exist not only in access to health insurance but also in take-up of insurance, access to care, and the incidence of health conditions. We need to create a comprehensive safety net for young children that includes automatic eligibility for basic health coverage under Medicaid unless parents opt out by enrolling children in a private program; health and nutrition services for pregnant women and infants; quality preschool; and home visiting for infants and children at risk. Such a program is feasible and would be relatively inexpensive. Currie, J. 2009-11-01 doi:10.1542/peds.2009-1100M Policy Interventions to Address Child Health Disparities: Moving Beyond Health Insurance American Academy of Pediatrics SUPPLEMENT_3 124 254 246 2009-11-01 SUPPLEMENT ARTICLES