Faculty Bibliography

Infants born with low or high ("at-risk") birthweights are at greater risk of adverse health outcomes across the life course. Our objective was to examine whether geographic hotspots of low and high birthweight prevalence in New York City had different patterns of neighborhood risk factors. We performed census tract-level geospatial clustering analyses using (1) birthweight prevalence and maternal residential address from an all-payer claims database and (2) domains of neighborhood risk factors (socioeconomic and food environment) from national and local datasets. We then used logistic regression analysis to identify specific neighborhood risk factors associated with low and high birthweight hotspots. This study examined 2088 census tracts representing 419,025 infants. We found almost no overlap (1.5%) between low and high birthweight hotspots. The majority of low birthweight hotspots (87.2%) overlapped with a socioeconomic risk factor and 95.7% overlapped with a food environment risk factor. Half of high birthweight hotspots (50.0%) overlapped with a socioeconomic risk factor and 48.8% overlapped with a food environment risk factor. Low birthweight hotspots were associated with high prevalence of excessive housing cost, unemployment, and poor food environment. High birthweight hotspots were associated with high prevalence of uninsured persons and convenience stores. Programs and policies that aim to prevent disparities in infant birthweight should examine the broader context by which hotspots of at-risk birthweight overlap with neighborhood risk factors. Multi-level strategies that include the neighborhood context are needed to address prenatal pathways leading to low and high birthweight outcomes.

To mitigate the negative impact of resource needs on child health, practices serving low-income immigrant families have implemented screening programs to connect families to community resources. Little is known about how duration of US residence relates to patterns of resource needs and indicators of acculturation such as community resource knowledge/experience or self-efficacy. We conducted a cross-sectional analysis of a convenience sample of immigrant families with young children at an urban primary care clinic. These families were seen 5/2018"“1/2020 for well child care, screening positive for ≥1 social need using a tool derived from Health Leads. Analysis of 114 families found that newly arrived families with a shorter duration of US residence (≤5 years) were more likely to report immediate material hardships like food insecurity and need for essential child supplies. Newly arrived families were also less likely to have access to technology resources such as a computer or smartphone. Long-term families with a longer duration of US residence (≥15 years) were more likely to report chronic needs like poor housing conditions, but also reported increased community resource knowledge/experience and increased self-efficacy. Primary care pediatric practices should assess immigration contextual factors to identify subgroups such as newly arrived families with young children to target resources (e.g., increase screening frequency) or enhance services (e.g., patient navigators) to relieve resource needs.

Social determinants of health influence child health behavior, development, and outcomes. This paper frames social capital, or the benefits that a child receives from social relationships, as a positive social determinant of health that helps children exposed to adversity achieve healthy outcomes across the life course. Children are uniquely dependent on their relationships with surrounding adults for material and non-material resources. We identify and define three relevant aspects of social capital: 1) social support, which is embedded in a 2) social network, which is a structure through which 3) social cohesion can be observed. Social support is direct assistance available through social relationships and can be received indirectly through a caregiver or directly by a child. A child's social network describes the people in a child's life and the relationships between them. Social cohesion represents the strength of a group to which a child belongs (e.g. family, community). Pediatric primary care practices play an important role in fostering social relationships between families, the health care system, and the community. Further research is needed to develop definitional and measurement rigor for social capital, to evaluate interventions (e.g. peer health educators) that may improve health outcomes through social capital, and to broaden our understanding of how social relationships influence health outcomes.

OBJECTIVE:To assess relationships between material hardships, shortened sleep duration, and suboptimal sleep practices across infancy and toddlerhood in low-income Hispanic families. METHODS:We analyzed longitudinal data of 451 low-income Hispanic mother-child pairs from a child obesity prevention trial. During infancy and toddlerhood, we used adjusted linear regression to assess associations between material hardship (financial difficulty, food insecurity, housing disrepair, multiple hardships), sleep duration (24-hour, night), and the number of suboptimal sleep practices (e.g., later bedtime, co-sleeping). We used adjusted linear regression to assess the longitudinal association between the number of suboptimal sleep practices in infancy and toddlerhood, and tested whether specific or multiple hardships moderated this association. RESULTS:In infants, financial difficulty and multiple hardships were associated with decreased night sleep (B=-0.59 hours, 95% CI: -1.04, -0.14; and B=-0.54 hours, 95% CI: -1.00, -0.08). Housing disrepair was associated with decreased 24-hour sleep (B=-0.64 hours, 95% CI: -1.29, -0.01). In toddlers, each additional suboptimal sleep practice was associated with a decrease in night sleep (B=-0.19 hours, 95% CI: -0.29, -0.09). Each additional suboptimal sleep practice in infancy was associated with a 0.30 increase in the number of suboptimal sleep practices in toddlerhood (p<0.001), with greater increases for those with food insecurity or multiple hardships. CONCLUSION/CONCLUSIONS:Specific and multiple hardships shortened sleep duration during infancy, and moderated the increase of suboptimal sleep behaviors between infancy and toddlerhood. Future studies should consider these early critically sensitive periods for interventions to mitigate material hardships and establish healthy sleep practices.

OBJECTIVE:Inpatient discharge education is often suboptimal. Measures of parents' perceived comprehension of discharge instructions are included in national metrics given linkage to morbidity; few studies compare parents' perceived and actual comprehension. We (1) compared parent perceived and actual comprehension of discharge instructions and (2) assessed associations between plan complexity and parent health literacy with overestimation of comprehension (perceive comprehension but lack actual comprehension). METHODS:Prospective cohort study of English/Spanish-speaking parents (n=192) of inpatients ≤12 years old and discharged on ≥1 daily medication from an urban public hospital. We used McNemar's tests to compare parent perceived (agree/strongly agree on 5-point Likert scale) and actual comprehension (concordance of parent report with medical record) of instructions (domains: medications, appointments, return precautions, and restrictions). Generalized estimating equations were performed to assess associations between low parent health literacy (Newest Vital Sign score ≤3) and plan complexity with overestimation of comprehension. RESULTS:Medication side effects were the domain with lowest perceived comprehension (80%), while >95% of parents perceived comprehension for other domains. Actual comprehension varied by domain (41-87%) and was lower than perceived comprehension. Most (84%) parents overestimated comprehension in ≥1 domain. Plan complexity (adjusted odds ratio [aOR] 3.6 [95% CI 2.9-4.7]) and low health literacy (aOR 1.9 [1.3-2.6]) were associated with overestimation of comprehension. CONCLUSIONS:Parental perceived comprehension of discharge instructions overestimated actual comprehension in most domains. Plan complexity and low health literacy were associated with overestimation of comprehension. Future interventions should incorporate assessment of actual comprehension and standardization of discharge instructions.

OBJECTIVE:To examine associations between parent health literacy, discharge plan complexity, and parent comprehension of and adherence to inpatient discharge instructions. STUDY DESIGN/METHODS:This was a prospective cohort study of English/Spanish-speaking parents (n = 165) of children ≤12 years discharged on ≥1 daily medication from an urban, public hospital. Outcome variables were parent comprehension (survey) of and adherence (survey, in-person dosing assessment, chart review) to discharge instructions. Predictor variables included low parent health literacy (Newest Vital Sign score 0-3) and plan complexity. Generalized estimating equations were used to account for the assessment of multiple types of comprehension and adherence errors for each subject, adjusting for ethnicity, language, child age, length of stay, and chronic disease status. Similar analyses were performed to assess for mediation and moderation. RESULTS:Error rates were highest for comprehension of medication side effects (50%), adherence to medication dose (34%), and return precaution (78%) instructions. Comprehension errors were associated with adherence errors (aOR, 8.7; 95% CI, 5.9-12.9). Discharge plan complexity was associated with comprehension (aOR, 7.0; 95% CI, 5.4-9.1) and adherence (aOR, 5.5; 95% CI, 4.0-7.6) errors. Low health literacy was indirectly associated with adherence errors through comprehension errors. The association between plan complexity and comprehension errors was greater in parents with low (aOR, 8.3; 95% CI, 6.2-11.2) compared with adequate (aOR, 3.8; 95% CI, 2.2-6.5) health literacy (interaction term P = .004). CONCLUSIONS:Parent health literacy and discharge plan complexity play key roles in comprehension and adherence errors. Future work will focus on the development of health literacy-informed interventions to promote discharge plan comprehension.