What is health equity and why does it matter? According to the Robert Wood Johnson Foundation, health equity, at its most fundamental, means that everyone has a fair and just opportunity to be as healthy as possible.
But for individuals and communities facing systemic racism and barriers—not only to quality health care—but also to quality food, education, and housing, that opportunity can be scant or missing altogether. For children, the consequences of health inequity can be particularly profound: Early childhood adversity can harm a young child’s brain and psychological systems, leading to long-term disparities in health and social outcomes. And since children rely on their parents, caregivers, families, and other adults to make sure they are provided for and are growing in a developmentally appropriate manner, it is especially critical that their needs be prioritized.
In pediatric primary care, there exists a largely untapped opportunity to advance health equity for children. A nearly universal touchpoint for families, particularly for children under age three, pediatric primary care providers can help combat—and if I dare say, even reverse—the impact of adversity on children by intervening early with families, supporting caregivers, and providing interventions that promote healthy development. To foster this vital opportunity, UHF launched the statewide Pediatrics for an Equitable Developmental Start (PEDS) Learning Network in the summer of 2020. The multilevel intervention includes a professional fellowship program designed to develop early career clinicians into champions of change who can disrupt the status quo and advance health equity by transforming children’s primary care.
The following is a sampling of lessons learned from the inaugural 15-month fellowship cohort, which concluded in December 2021:
1. It Takes a Village… but SomeONE Must Mobilize It
In Buffalo, a pediatrician, created an indoor gardening station in the waiting area of a community pediatric clinic as well as a weekly farmer’s market. The goals were simple yet ambitious: get kids and families excited about eating healthy and growing their own food, and increase access to good, local food options. Through outreach and collaborative work, this PEDS Network fellow was able to coordinate with a local mobile farmer’s market to fund $6 voucher food cards for pediatric families to purchase fresh vegetables and fruit right outside the pediatric community clinic. The fellow also partnered with community-based organizations to promote and provide accessibility to community gardens, their crops, and healthy recipes. Indeed, it takes a village to create and sustain lasting impacts for children and their families, but it also often takes one individual—one change agent—to mobilize community partners and clinic staff. As a result, there is a delightful sight in the corner of the waiting room, sweetened by the aroma of fresh herbs beckoning to be harvested by little hands.
2. Trauma-Informed Care is Necessary for Quality Pediatric Health
In the spirit of a full-service medical home, a licensed mental health professional from the Capital region saw the need to develop and implement a trauma-informed care training program for pediatric residents focused on the impact of trauma and implicit bias on patient health. Physicians inevitably bring who they are and what they know into the exam room with patients, and so it is crucially important to increase their comfort levels and knowledge of what it means to provide trauma-informed physical exams and interviews, to better coordinate services for high-risk patients, and have a better understanding of specific patient populations. The resident training series has since been invited to expand and be offered to first year residents in the hospital and additionally presented to all attending physicians in the hospital-based pediatric practice. It’s clear that the training program will successfully continue beyond the scope of the fellowship.
The project also helped shine a light on the large need for behavioral health services in the Capital region. Due to the success of this project, the practice will be spearheading a new initiative focused on community outreach to address inequities in behavioral health. The PEDS Network fellow submitted a grant proposal and was awarded $100,000 to fund this new initiative and was subsequently promoted because of her efforts.
3. Leadership Matters…
Leadership engagement is essential to practice change and to aligning the necessary resources and people to accomplish the desired outcome. Another fellowship project developed by a licensed social worker showed us that, despite the best of intentions and a well-developed strategy, an absence of leadership support can cause significant challenges. The goal was to improve the screening rates of developmental questionnaires and social needs and improve the quality of care by ensuring children and families receive adequate referral and services. At the beginning of the program, the hospital-based clinic was still very much in the throes of operating during the COVID-19 pandemic; thus, support for the project was short-lived. Throughout the program’s duration, several management changes adversely affected the ability to secure approvals, schedule meetings, and build the staff support necessary to get the project off the ground. In addition to a change champion, it is imperative to also secure key leadership buy-in to effectively execute that change.
4. No Need to Reinvent the Wheel!
Though we hear this advice all the time, there’s no need to always start from scratch. In Long Island City, Queens, a pediatrician decided to create a project to improve parental recognition of developmental delays using “Milestone Toolkits” developed in multiple languages to meet the needs of the clinic’s diverse patient population. The idea was to provide a user-friendly version of the existing CDC’s “Learn the Signs. Act Early.” program, which is designed to help parents learn and look for developmental milestone behaviors, and act early by mentioning it to the pediatrician if there is a concern. The pediatrician had the content translated into Bengali and Arabic, in addition to English and Spanish on laminated cards. To reinforce parents’ understanding and engagement, the doctor provided a tangible item (e.g., a rattle, teething ring, sippy cup) that corresponded to key developmental milestones. Although the CDC’s program wasn’t new, customizing it to meet the needs of the clinic’s patient population was indeed a novel idea.
These examples clearly demonstrate that progress toward child health equity is possible, even in the face of institutionalized processes that were intentionally built to thwart children and families of color and set them up for failure before they even took their first step. By taking small, strategic steps themselves, the PEDS fellows have started to chart a meaningful way forward. In contemplating this work, I think of the words of Edward Everett Hale:
“I am only one, but still, I am one. I cannot do everything, but still, I can do something and because I cannot do everything, I will not refuse to do the something that I can do.”
Susan Olivera, MPH, is a senior program manager at UHF and oversees the Pediatrics for an Equitable Developmental Start (PEDS) Learning Network.
United Hospital Fund has a long history of bringing together diverse perspectives to address critical challenges in health care in New York. In the current crisis, it’s more important than ever to hear from all parts of the health care system. Today’s commentary from UHF’s Susan Olivera highlights lessons learned from our PEDS Learning Network’s health equity projects. – UHF President Tony Shih