Structural racism and both explicit and implicit bias lead to poor individual and population health outcomes.1, 2 The COVID-19 pandemic has highlighted and further exacerbated existing racial, ethnic, and socioeconomic inequities within health care and other sectors.3, 4 Simultaneously, the maltreatment, brutality, and murders of Black people disproportionately affected by our criminal justice system have heightened national focus and conversation on racism. Amidst these crises, we as residents felt an augmented responsibility to address these issues in creative and impactful ways. Specifically, we aimed to discuss, reflect upon, and develop solutions for the stark inequities we were witnessing during the pandemic and stimulate conversations within our multidisciplinary health care community. Health Equity Rounds (HER) was our platform to accomplish these goals. HER is a trainee-led, case-based, longitudinal, and multidisciplinary grand rounds conference curriculum established in the Departments of Pediatrics at Boston Medical Center (BMC) in 2016 and Boston Children's Hospital (BCH) in 2017.5 The goal of each HER is to discuss how structural racism and bias contribute to health and health care inequities, engage in self-reflection, and learn tools to mitigatethe impact of racism and bias on clinical care. HER participants share a communal sense of accountability and vulnerability that allows our institutions to confront our role in participating in and perpetuating a system fraught with racism and inequities. Our group of residents and faculty advisors utilised the HER framework to execute a year-long educational series across our institutions (BMC and BCH) focused on understanding new and existing health inequities and advancing anti-racism through the lens of the pandemic. The presenting team for each session consisted of a group of three to four residents, a senior resident leader, a faculty advisor, and panellists who were institutional experts or community leaders. Each HER was presented via ZOOM® during departmental grand rounds with a multidisciplinary audience of up to 130 participants. Table 1 outlines the content presented and resources provided in each conference. The most pressing pandemic-related inequities occurring at the time of each HER informed the topics. The first HER described COVID-19-related health disparities and illustrated connections between these disparities and legacies of structural racism. The second occurred during ongoing debate on school reopening and highlighted resultant inequities. The third occurred as vaccine distribution was ramping up and focused on community perspectives and the role of medical distrust in COVID-19 vaccine deliberation. COVID-19 Health Equity and Advocacy June 2020 Boston Children's Hospital - Describe the link between structural racism and implicit bias - Correlate pre-existing socioeconomic disparities in Boston to current disparities in the ability to practice social distancing - Examine racial inequities in COVID-19 testing and treatment - Evaluate gaps and limitations in data collection to fully understand inequities in the COVID pandemic - Highlight opportunities for advocacy - Racial and ethnic inequities in COVID-19 cases, testing access, crisis standards of care, and therapeutic trial enrolment - Structural and historical factors contributing to these racial and ethnic inequities, including disparities in housing stemming from redlining and generational wealth, employment type, transportation access, and built environment - Lack of rigorous data collection related to racial and ethnic inequities in COVID-19 - Links to advocacy opportunities for state and national policy changes, including how to identify and contact legislators - Social media advocacy guidelines - Existing resources to address housing and food insecurity Multisystem Inequities due to School Closures September 2020 Boston Medical Center - Outline the disparate impacts of school closures on children and families in terms of school education and services, food insecurity, and internet access - Highlight recommendations for school opening from the state of Massachusetts, American Academy of Pediatrics, and Centers for Disease Control with a focus on how equity and racial justice is implicated in guidelines - Factors contributing to racial and ethnic educational inequities in the pandemic, including socioeconomic status, access to technology, limited English proficiency, and student disability status- History of redlining in Boston leading to “digital redlining” - Impacts of school closures on learning, food security, digital access, and other essential school services - How food insecurity before and during the pandemic was exacerbated by school closures - Perspective-taking exercise - Participants asked to share de-identified patient stories and personal experiences and engage in community reflection - Virtual polls - Lead family navigator, BMC Paediatrics - Director, BMC Individualised Education Plan Clinic - Director, BMC Developmental and Behavioural Paediatrics - Social worker, Boston Public Schools (BPS) - Community resources to help advocate for digital equity - Resources to address food insecurity - Resources on school services from BPS Why Hesitate to Vaccinate? February 2021 Boston Medical Center - Identify concerns patients and community members have expressed regarding the COVID-19 vaccine - Distinguish different types of vaccine hesitancy - Describe the historical and current contexts that contribute to lack of trust in the medical system - Utilise tools to connect with patients and provide education to inform personal decision making about the COVID-19 vaccine - Timeline of events that have led to medical distrust (i.e., Tuskegee syphilis study, J. Marion Sims experiments on enslaved Black women) - Examples of medical error contributing to medical distrust (i.e., thalidomide and phocomelia) - Present-day forces leading to medical distrust among communities of colour including negative encounters with police, perceived discrimination, ongoing trauma, and lack of physician workforce diversity - Perspective taking exercise - Participants asked to share personal concerns and de-identified stories of conversations with patients and families about the COVID-19 vaccine - Lead accountable care organisation specialist, BMC - Program coordinator, BMC Pediatric Mobile Health Unit - Assistant Professor, BMC Infectious Diseases - COVID-19 vaccine communication toolkits - Multilingual vaccine resources - BMC community vaccine sites Through our experience, we found that issues of health equity can be discussed effectively during a pandemic and that real time issues encountered can be essential learning opportunities for mitigating inequities. Focusing each conference on current pandemic-related inequities allowed us to engage busy clinical staff in open and honest conversations about how racism and bias were affecting our patients and community. We engaged participants in a compelling and actionable way by using timely, real-world examples and providing resources that could be immediately utilised, a method that is often not afforded when discussing more theoretical or historical examples of inequities. Furthermore, while the conferences were framed around pandemic-related problems, we were able to disseminate information on addressing health inequities that could be applied in broader contexts. Focusing each conference on current pandemic-related inequities allowed us to engage busy clinical staff in open and honest conversations. We also discovered several benefits of a virtual platform as compared with our traditional in-person format for addressing issues and fostering discussion related to health equity. A moderator used the conference live chat and interactive prompts to engage attendees in rich, dynamic conversations about racism and bias, allowing for discussions to start among participants that could continue beyond the allocated conference time. We also provided links to resources and tools through the chat, helping us focus on actionable items that attendees could take away from the conference and use to mitigate inequities. Lastly, the broad reach of the platform promoted the inclusion of participants across the city and country who interface with health equity in different ways, promoting collaboration and increased awareness of the widespread challenges plaguing our health care system and our patients. Adapting an established framework, we facilitated health equity education and dialogue through the lens of COVID-19 to a large, multidisciplinary, and multi-institutional audience. We discussed relevant issues in the setting of an evolving medical, political, and social climate and provided a dedicated platform for health care staff to prioritise longitudinal engagement in learning and reflecting on inequities, structural racism, and bias. In future HER iterations, we will carry forward what we learned through presenting this series, including the advantages of focusing on equity issues related to current events, providing relevant and tangible resources, and optimising interactive discussions within a virtual or hybrid platform. This series focused on the COVID-19 pandemic, but the lessons learned will help us address inequities that existed before and will persist beyond the pandemic through fostering intentional conversations about our practices, systems, and institutions. We facilitated health equity education and dialogue through the lens of COVID-19 to a large, multidisciplinary, and multi-institutional audience. The lessons learned will help us address inequities that existed before and will persist beyond the pandemic. We would like to thank Dr. Catherine Michelson and Dr. Robert Vinci for their ongoing support of Health Equity Rounds. We also acknowledge our panellists and guest speakers, Dr. Soukaina Adolphe, Dr. Sabrina Assoumou, Dr. Marilyn Augustyn, Justin Braman, LICSW, Ivys Fernandez-Pastrana, JD, Gladys Quino, BS, and Krishna Varela, MBA, for their contributions to these conferences. Finally, thank you to all those who have participated in Health Equity Rounds and contributed to rich, productive, and vulnerable conversations for our patients and community. The authors have no conflicts of interest to disclose. No financial funding was received for this work. This work did not involve any research or data collection conducted on human subjects and therefore did not require the IRB review process.
Objective: The authors sought to determine whether a multicomponent, community-based program for preventing maternal depression also promotes engagement with mental health services for individuals with persistent symptoms. Methods: Mothers of children enrolled in Head Start were randomly assigned between February 2011 and May 2016 to Problem-Solving Education (PSE) (N=111) or usual services (N=119) and assessed every two months for 12 months. Results: Among 230 participants, 66% were Hispanic; 223 participants were included in the analysis. For all PSE participants, engagement with specialty mental health services increased from approximately 10% to 21% between two and 12 months. The PSE group was more likely than the control group to be engaged in specialty services at 12 months (adjusted odds ratio [AOR]=2.36, 95% confidence interval [CI]=1.07–5.20), and the rate of engagement with specialty services over time (treatment × time interaction) favored PSE (p=.016). Among PSE participants with persistent depressive symptoms over the follow-up period, engagement with specialty services increased from 12% (two months) to approximately 46% (12 months), whereas among control group participants, engagement fluctuated between 24% and 33%, without a clear trajectory pattern. At 12 months, PSE participants with persistent symptoms were more likely to engage with specialty care compared with their counterparts in the control group (AOR=6.95, CI=1.50–32.19). The treatment × time interaction was significant for the persistently symptomatic subgroup (p=.029) but not for the episodically symptomatic or the asymptomatic subgroups. Conclusions: Embedding mental health programs in Head Start is a promising strategy to engage parents with depressive symptoms in care, especially those with persistent symptoms.
Child maltreatment remains a concerning source of morbidity and mortality in the United States, where more than 600,000 children are victims of abuse each year, with well-described, long-term consequences for physical and mental health. However, the US child welfare system is characterized by systemic racism and inequity. Black and Native American children are more likely to be evaluated and reported for suspected abuse despite evidence that race does not independently change their risk of being abused. Once reported to child protective services (CPS), these children are more likely to be removed from their homes and less likely to be reunited with their families than White children. Much of the inequity in this system starts at the front door, where a growing body of research demonstrates that bias regularly infiltrates decision-making in the initial clinical evaluation and management of suspected abuse. Minority children presenting to emergency departments (ED) are more likely to receive diagnostic testing and are more likely to be referred to CPS. In this editorial, we argue for the application of an equity lens to child protection in the ED. We discuss how emergency physicians can balance efforts to protect children from abuse with the imperative to protect children and families from the harms of an inequitable child welfare system. Our discussion concludes with concrete recommendations for emergency clinicians to participate in active bias mitigation and thoughtfully navigate their responsibilities as mandated reporters.
In the USA, there are well-described racial disparities in medical care with black patients, as well as other racial and ethnic minorities, consistently faring worse than white patients across specialties and diagnoses.1 Similar disparities have been found among black and minority ethnic patients in the UK.2 ,3 A 2002 report by the USA Institute of Medicine (IOM) determined that the ‘quality of care received by racial and ethnic minorities in this country is generally lower than that provided to the majority population’,1 and persistent racial discrimination and bias contribute to poor health outcomes. In the decade that has followed the IOM report, few racial disparities have been eliminated, even as access to health services has improved.4
Medical schools and teaching hospitals—with their focus on training future doctors, providing patient care and conducting clinical research—have an important role to play in addressing racial disparities and improving healthcare quality. There is ample evidence that increasing the diversity of the physician workforce to better reflect the diversity of the general population—in particular by training and hiring greater numbers of providers from under-represented racial and ethnic backgrounds—directly benefits patients, medical students and …
Objective To examine cross-sectional associations of food and housing security risks and healthy lifestyle parenting behaviors related to nutrition and physical activity among families with children with overweight/obesity. Methods We surveyed 407 parents of children ages 6–12 years with overweight/obesity. Exposures were measures of food and housing insecurity risk. Outcomes were healthy lifestyle parenting behaviors related to nutrition and physical activity. Logistic regression models for each exposure-outcome relationship were adjusted for parental educational attainment, parental cohabitation status, household size, and household income. Results In multivariable-adjusted models, food insecurity was associated with significantly lower odds of parent modeling exercise {aOR 0.60 [95% confidence interval (CI): 0.37, 0.96]} and parent modeling eating healthy foods [aOR 0.42 (95% CI: 0.24, 0.73)]. Housing insecurity was associated with significantly lower odds of parent modeling exercise [aOR 0.57 (95% CI: 0.35, 0.95)]. Conclusions Food insecurity and housing insecurity may be barriers to parents adopting and modeling healthy lifestyle parenting behaviors related to physical activity and nutrition.
Children in low-income families are at risk for delayed diagnosis of autism spectrum disorder (ASD). The cascade-of-care model, which examines steps of care for quality and efficacy, can identify lesions in the process for evaluation and diagnosis for children at risk for ASD. Little is known about predictors that influence key steps in this process. We performed a retrospective chart review of 110 children under age five years from an academic medical center with social communication concerns. We assessed predictors of age of referral for ASD diagnostic evaluation, time to diagnosis, and likelihood of diagnostic completion. Children with continuity of primary care were referred at an earlier age than those receiving primary care at multiple centers. Compared with children with missed visits, children attending all well-child visits had a shorter median time to diagnosis. These findings illustrate a need for primary medical homes to facilitate early and timely ASD evaluations.
To gather baseline data for a longitudinal study to determine whether participation in a fair trade economic intervention increases household socioeconomic status and has an impact on nutrition status in children less than 5 years of age.
Methods
All data were collected via door-to-door interviews in 5 communities in Southern Honduras. A household questionnaire was administered to each family with children less than 5 years of age, and a child survey was conducted for each individual child. Involvement with a fair trade intervention was determined in the household survey via participation with a local cashew cooperative known as APDP. Nutritional status was evaluated by measures of weight-for-height (wasting), height-for-age (stunting), and weight-for-age (underweight). These indices were analyzed using the Z-score method and were presented as standard deviations from the median of the 2002 CDC reference population. Socioeconomic status in this study was defined as assets. Household assets were assigned a factor score; families were then ranked based on the total asset score of their household.
Results
A total of 335 children were studied, with 199 households surveyed. Our data displayed 136 out of 335 children were stunted, 102 out of 335 were underweight, and 19 out of 335 were wasted There was a significant relationship (p-value = .05) between APDP participation and number of children stunted. There was no significant difference between genders. Other factors found to be significant indicators of malnourishment included breastfeeding greater than 1 year of age, which was associated with an increased percentage of wasting, and increased Haemophilus influenza type b (Hib) vaccine compliance, which was related to a decreased rate of stunting.
Conclusion
Chronic childhood malnutrition was decreased in households involved with APDP fair trade interventions. While a cause and effect relationship cannot be determined in a cross-sectional study such as this one, this suggests an association between involvement in an economic intervention project and decreased rates of chronic childhood malnutrition. Future data collection with this project will continue to assess this relationship over time.
