The Mitigating Toxic Stress study design: approaches to developmental evaluation of pediatric health care innovations addressing social determinants of health and toxic stress

Julie S Mccrae,Kaela Byers,Jo Ann L Robinson,Angeline K Spain,Jennifer L Axelrod

doi:10.1186/s12913-021-06057-4

Abstract

BackgroundHealth care administrators must establish and promote effective partnerships with community agencies to address social determinants of health, including reducing exposure of infants and young children to chronic stress. Because infants’ experiences are inextricably tied to their caregivers, an important target for mitigating “toxic” stress exposure in early childhood is through reducing parents’ experiences of chronic stress in addition to protecting children from direct experiences of harm such as physical or sexual abuse. Conducting screening to identify when children are exposed to early life adversity is a first step; connecting families to needed support services is an essential component to addressing identified challenges. This paper presents the methodology of a three-year study of health care systems innovations designed to engage and support parents of infants to prevent and mitigate children’s toxic stress exposures.MethodsKey study features included: 1) multi-component study in five U.S. communities and nine pediatric health care clinics and the families they serve, 2) a developmental evaluation approach to describe how innovations are experienced over time at three levels—community systems, pediatric providers, and families, and 3) rapid cycle feedback conducted with communities, clinics and families to co-interpret data and findings. Data sources included: 1) focus groups and interviews with community stakeholders, clinic staff, and families, 2) electronic health record and Medicaid services data extracted to assess health care quality, utilization, and financial impact, and 3) clinic-recruitment of 908 parents of infants in a longitudinal survey. Results. The sample is briefly characterized based on responses to the enrollment phase of the parent survey.ConclusionsWe discuss the study design elements’ contribution to generating evidence needed by innovators, communities, and clinics to modify and sustain investments in these innovations to prevent or mitigate the effects of exposure to toxic stress on young children.

Highlights

Health care administrators must establish and promote effective partnerships with community agencies to address social determinants of health, including reducing exposure of infants and young children to chronic stress
Study overview This paper describes a developmental evaluation study using mixed methods to understand the experiences of five communities, nine health care clinics, and 908 families in the implementation of two healthcare/early childhood systems innovations to promote resilience and reduce stress in the child’s family during the first year of life
Developmental Understanding and Legal Collaboration for Everyone (DULCE) clinics were recruited by the research team and Center for the Study of Social Policy (CSSP), and interested I-SCRN clinics responded to a recruitment flyer distributed by the research team and the Academy of Pediatrics’ (AAP)

Summary

Introduction

Health care administrators must establish and promote effective partnerships with community agencies to address social determinants of health, including reducing exposure of infants and young children to chronic stress. Social determinants of health are the conditions or circumstances in which people are born, grow, live, work, and age, and the wider set of forces and systems shaping the conditions of daily life [1, 2]. Protective factors including supportive relationships, and access to basic needs such as high-quality food and transportation, can mitigate chronic stressors and promote resilience. These positive childhood experiences in the face of adversity have been shown to independently predict adult health [9]. The American Academy of Pediatrics and the American Academy of Family Physicians are just two of the professional practice organizations in the U.S that underscore pediatric and family health care providers’ role in addressing the social needs of families [10, 11]

Methods

Results

Discussion

Conclusion