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The Social Determinants of Health and Well-Child Visits: How are

they related?

By: Ashley Cram

Senior Honors Thesis

BSPH Health Policy and Management Gillings School of Global Public Health University of North Carolina at Chapel Hill

May 1, 2020

Approved:

______________________________ Morris Weinberger, PhD, Thesis Advisor UNC Gillings School of Global Public Health

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Table of Contents

Abstract...2

Introduction...5

Research Question...6

Literature Review...6

Well Child Visits (WCV)...6

The Social Determinants of Health (SDOH)...6

Food Insecurity...7

Housing Insecurity...8

Insurance Insecurity...8

Social Determinants of Health and Well-Child Visits...8

Methods...9

Findings...10

Sample Characteristics...10

Linear Regression Analysis...14

Discussion...15

Acknowledgements...18

Works Cited...19

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Abstract

Background: In the first year of life, children are recommended to attend 6 well-child visits (WCVs) to monitor growth and development, receive vaccinations, and more. Food insecurity, housing insecurity, and insurance insecurity are social determinants of health (SDOH) that have been found to impact health outcomes in children. With limited literature on the impact of SDOH on attendance at WCVs, this study aims to identify the impact that food, housing, and insurance insecurity have on attendance at the 6 recommended WCVs in the first year of life.

Methods: We conducted a secondary data analysis to identify the impact of food, housing, and insurance insecurity on children that receive care at the UNC Children’s Primary Care Clinic. A parent-completed SDOH questionnaire was used to determine if patients were food, housing, or insurance insecure. These insecurities were the independent variables and the number of missed WCVs was the dependent variable. T-tests and linear regression analyses were used to determine if these variables were associated.

Findings: In this sample, 4.4% of patients were housing insecure, 17.0% were food insecure, and 36.5% were insurance insecure. None of the insecurities were found to be significantly associated with the number of missed WCVs. However, male gender and Asian race/ethnicity were found to be significant covariates, accounting for an increase and decrease in the number of missed WCVs respectively.

Discussion: The SDOH have been found to significantly affect health outcomes across populations. In order to effectively care for children in the first year of life, it is important to ensure that they are able to attend WCVs in order to receive proper immunizations and monitor development. This study found that food, housing, and insurance insecurity were not

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Introduction

Awareness that social factors impact health outcomes is not new to healthcare providers and the public health workforce. However, over the past few decades, there has been an

increased commitment to identify these non-clinical determinants of health and address them through enhanced clinical care and policies that improve population health. The Social

Determinants of Health (SDOH) are conditions in which people are born, grow, live, work and age that shape health [1]. Providers and public health officials are beginning to use social risk screening tools to ask patients about these conditions, in an effort to address and minimize their impact on health outcomes.

Food insecurity and housing insecurity are common SDOH that are negatively associated with health outcomes [2]. Food insecurity is the lack of available nutritionally adequate foods due to limited money or other resources [3]. Children who are food insecure are twice as likely to report having fair or poor health, and 1.4 times as likely to have asthma, compared to food secure children [2]. Housing insecurity is defined as high housing costs in proportion to income, poor housing quality, unstable neighborhoods, overcrowding, or homelessness [4]. Patients who report housing insecurity are more likely to forego health care and lack a usual source of care, resulting in poor access to primary and preventive care [5]. Additionally, insurance coverage is an

important factor in accessing health care services. Uninsured individuals are more likely to have poorer health outcomes and less likely to access healthcare services [6].

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intervention for health conditions, or opportunities for parents to learn about healthy lifestyle practices that could foster good health [8].

This study aimed to identify the impact of food insecurity, housing insecurity, and insurance insecurity, on successful completion of recommended WCVs in the first year of life. Patient-record EMR data, in addition to patient reported data collected using a written SDOH questionnaire, was analyzed to identify individuals with food, housing and/or insurance insecurity. This study addresses the lack of literature concerning the impact of the SDOH on WCVs and provides evidence to guide the practice of addressing the social determinants of health in children and new mothers.

Research Question

What is the impact of food insecurity, housing insecurity, and insurance insecurity on the number of missed WCVs in the first year of life?

Literature Review

Well Child Visits (WCV)

WCVs are crucial for tracking childhood growth and development by providing

opportunities to measure physical, cognitive, emotional, and social development that can serve as milestones and indicators of health in the future [9]. Additionally, WCVs are opportunities to talk about health prevention, such as obtaining proper immunizations and establishing healthy behaviors that can prevent chronic conditions [9].

The Social Determinants of Health (SDOH)

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housing quality can directly impact conditions such as asthma, SDOH can also lead to missed health appointments and inability to receive care, which can exacerbate many health conditions [10]. For example, attending recommended WCVs was found to be significantly lower among patients who lived at 100-199% of the federal poverty level and whose parents did not have a high school diploma [10].

Food insecurity and housing insecurity are measures of socioeconomic status that can impact access and utilization of health care services [11]. Insurance coverage is another

important determinant of a patient’s ability to attend recommended health care appointments or access care when needed [6]. Individuals who have adequate access to health care, specifically primary care, are more likely to receive appropriate care, prevent illness by promoting healthy behaviors, and lower mortality [6].

In 2004, Barbara Starfield proposed a national imperative to address SDOH in children because failing to do so introduced disparities that result from childhood circumstances [12]. To address these inequities, primary care providers have begun screening and referring patients to community resources in an effort to recognize and mitigate the effects of the SDOH on health outcomes [12]. SDOH screening at WCVs can lead to increased receipt of community-based resources for families, and ultimately better health outcomes [13]. Children are especially vulnerable to the effects of SDOH, and have a greater susceptibility to disease and poorer health outcomes as an adult due to the crucial development that occurs in the first few years of life [13]. Referring patients to community resources not only addresses the SDOH concern, but can increase patient’s access to care, and thus improve health outcomes.

Food Insecurity

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food insecurity can lead to nutritional deficiencies, ultimately affecting child development [14]. Furthermore, food insecurity can lead to unhealthy food related behaviors, such as skipping meals and consuming more calorie-dense foods [15]. Poverty significantly affects food insecurity, with 33% of those living at or below 133% of the federal poverty level being food insecure [15].

Housing Insecurity

Housing insecurity can be defined by difficulty paying rent, living in overcrowded or substandard conditions, and being evicted [11]. Housing insecurity has significant effects on health outcomes and is associated with measures of poorer health and development in very young children [4]. In children under three years old, housing is also an important marker for food insecurity and is found to lead to diminished weight and increased developmental risk [4]. Furthermore, housing and food insecurity are associated with poor access to healthcare and increased utilization of services [11].

Insurance Insecurity

Health insurance coverage can increase patients’ abilities to access needed health care services by reducing the financial burden individuals face when receiving health care services. Patients who are uninsured are more likely to have poorer health outcomes and less likely to receive adequate medical care [6]. Lack of health insurance in children is especially detrimental, as it often leads to increased hospitalizations and worse health outcomes later in life [16]. As a result, insurance coverage is crucial to the health of children and can significantly impact a child’s ability to both receive health services as well as reach important developmental milestones.

Social Determinants of Health and Well-Child Visits

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attendance at recommended WCVs. Therefore, it is important to consider how the factors of food insecurity, housing insecurity, and insurance insecurity impact child attendance at recommended well child visits in the first year of life.

Methods

The study was approved by the UNC Institutional Review Board. We conducted a

secondary data analysis to identify the impact of food insecurity, housing insecurity, and insurance insecurity on the number of missed WCVs (See Appendix I for information on data collection procedures). Subjects included children who completed at least one WCV (ICD10 code Z00.129 and Z00.121) at the UNC Primary Care Clinic since 2016 [17]. Food insecurity, housing

insecurity, and insurance insecurity were the independent variables, and were determined from a parent-completed social determinants of health questionnaire. The independent variables were coded in the medical record as yes or no and coded as 1 or 0, respectively. The dependent variable, missed WCVs, was determined using the weight measurement documented in the medical record for each child. This measurement is completed at every WCV, and therefore is the most standard measure of attendance at the visit. If a child had a weight measurement with a corresponding ICD10 WCV code, it was coded as a completed WCV. The number of completed WCVs was then summed to determine the total number of WCVs attended by that patient. The number of

completed WCVs was subtracted from 6 (WCVs at months 2, 4, 6, 9, 12, and 15).

To determine the impact of food insecurity, housing insecurity, and insurance insecurity on attendance at WCVs, we first conducted t-tests comparing the number of missed WCVs by

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gender, race/ethnicity, primary insurance, and gestational age. A 0.05 significance level was used for all analyses. A Poisson distribution was used to determine the fit of the data to the regression.

Findings

Sample Characteristics

Of the 364 patients in this sample, 71.4% of patients had Medicaid as their primary insurance, and only 3.3% were uninsured (Table 1); the sample was comprised almost equally of males and females.

Table 1. Characteristics of the Study Sample (N = 364)

Characteristic N (%)

Gender

Male 188 (51.6%)

Female 176 (48.4%)

Race/Ethnicity

Non-Hispanic White 89 (24.5%)

Non-Hispanic Black 107 (29.4%)

Hispanic 121 (33.2%)

Asian 26 (7.1%)

Other 19 (5.2%)

Insurance Status

Medicaid 260 (71.4%)

Blue Cross, Blue Shield 38 (10.4%)

Other Private 26 (7.1%)

State Health Plan 19 (5.2%)

Uninsured 12 (3.3%)

Tricare 8 (2.2%)

Insecurity

Insurance Insecurity 133 (36.5%)

Food Insecurity 62 (17.0%)

Housing Insecurity 16 (4.4%)

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were 62 (17%) individuals who screened positive for food insecurity (Figure 1). Of those found to be food-insecure, 48.4% were male and 51.6% were female. Additionally, 87.1% had Medicaid as their primary insurance, 6.5% had Blue Cross, Blue Shield, 3.2% had other private insurance, and 1.6% had Tricare. Lastly, 40.3% were Non-Hispanic Black, 33.9% were Hispanic, 19.4% were Non-Hispanic White, and 6.5% were of another race/ethnicity.

Figure 1. Individuals Screening Positive for Food Insecurity by Gender, Primary Insurance, and Race/Ethnicity (N = 62)

G e n d e r P r i m a r y I n s u r a n c e R a c e / E t h n i c i t y

0 10 20 30 40 50 60 70 Female, 32 Male, 30

Medicaid , 54 Blue Cross Blue

Shield, 4 Other Private, 2

Tricare, 1

Non-Hispanic Black , 25 Hispanic, 21 Non-Hispanic

White, 12 Other, 4

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Figure 2. Individuals Screening Positive for Housing Insecurity by Gender, Primary Insurance, and Race/Ethnicity (N = 16)

G e n d e r P r i m a r y I n s u r a n c e R a c e / E t h n i c i t y

0 2 4 6 8 10 12 14 16 18

Female, 10 Male, 6

Medicaid, 16

Hispanic, 8 Non-Hispanic

White, 3 Non-Hispanic

Black, 2 Asian, 2 Other, 1

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Figure 3. Individuals Screening Positive for Housing Insecurity by Gender, Primary Insurance, and Race/Ethnicity (N = 133)

G e n d e r P r i m a r y I n s u r a n c e R a c e / E t h n i c i t y

0 20 40 60 80 100 120 140

73 60

120

54

2 1

72

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The Welch’s two-sample T-tests found that none of the three insecurities were associated with WCVs (Table 2). The difference in the mean number of missed WCVs between the

insecurity present group and the no insecurity present group was not found to be statistically significant.

Table 2. Effect of Insecurity on Missed WCV

Type of Insecurity Insecurity Present (Mean) No insecurity (Mean)

T statistic P-value

Food Insecurity 0.582 0.516 0.558 0.578

Housing Insecurity

0.573 0.500 0.348 0.733

Insurance Insecurity

0.590 0.556 0.364 0.717

Linear Regression Analysis

The results of the generalized linear regression model for food insecurity show that it is not significantly (p<0.05) associated with the number of WCVs missed (Table 3). However, male gender and Asian race/ethnicity are significant (p<0.05) covariates. Male gender is associated with a 0.337 increase in missed WCVs. Asian race/ethnicity is associated with a 1.104 decrease in the number of missed WCVs.

Table 3. Generalized Linear Regression Analysis of Food Insecurity

Coefficient Estimate Standard Error P-value

Food Insecurity -0.194 0.196 0.324

Gender (male) 0.337 0.145 0.020*

Race/Ethnicity Asian -1.104 0.497 0.026*

Race/Ethnicity Hispanic -0.413 0.311 0.185

Race/Ethnicity Black -0.089 0.304 0.769

Race/Ethnicity White -0.450 0.319 0.158

Primary Insurance (public) 0.083 0.179 0.639

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The results of the generalized linear regression model for housing insecurity show that it is not significantly (p<0.05) associated with the number of WCVs missed (Table 4). However, male gender and Asian race/ethnicity are significant (p<0.05) covariates. Male gender is associated with a 0.345 increase in missed WCVs. Asian race/ethnicity is associated with a 1.062 decrease in the number of missed WCVs.

Table 4. Generalized Linear Regression Analysis of Housing Insecurity

Coefficient Estimate Standard Error P-value

Housing Insecurity -0.048 0.366 0.896

Gender (male) 0.345 0.147 0.020*

Race/Ethnicity Asian -1.062 0.496 0.032*

Race/Ethnicity Hispanic -0.376 0.311 0.227

Race/Ethnicity Black -0.133 0.306 0.662

Race/Ethnicity White -0.429 0.320 0.181

Primary Insurance (public) 0.081 0.183 0.660

Gestational Age -0.005 0.005 0.268

The results of the generalized linear regression model for insurance insecurity show that it is not significantly (p<0.05) associated with the number of WCVs missed (Table 5). However, male gender and Asian race/ethnicity are significant (p<0.05) covariates. Male gender is

associated with a 0.353 increase in missed WCVs. Asian race/ethnicity is associated with a 1.072 decrease in the number of missed WCVs.

Table 5. Generalized Linear Regression Analysis of Insurance Insecurity

Coefficient Estimate Standard Error P-value

Insurance Insecurity -0.071 0.164 0.666

Gender (male) 0.353 0.147 0.016*

Race/Ethnicity Asian -1.072 0.496 0.031*

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Race/Ethnicity Black -0.109 0.305 0.720

Race/Ethnicity White -0.429 0.321 0.181

Primary Insurance (public) 0.109 0.186 0.556

Gestational Age -0.005 0.005 0.288

Discussion

Literature shows that SDOH, including food, housing and insurance insecurity, negatively impact health outcomes. The results of this study showed that attendance at WCVs in the first year of life was relatively high, and that food insecurity, housing insecurity, and insurance insecurity do not significantly affect attendance. For this study, gender and race/ethnicity of the patient were significantly associated with WCVs, which may suggest different parenting styles lead to different behaviors in attendance. Families likely have different barriers to accessing care, such as other SDOH affecting attendance and perceived importance of WCVs.

In a recently published study, caregivers and clinicians identified factors such as

transportation, work and school schedules and even caregiver medical appointments as barriers to WCV attendance [18]. Additionally, patients may be less likely to attend WCVs after the first year of life [8]. Parents and caregivers may understand the importance of WCVs in the first year of life due to the vaccines and monitoring growth and development in the first year, and then face

barriers after that first year to attending later appointments. This study focused on attendance at WCVs in the first year of life, which consists of only six WCVs out of the standard 13

recommended in the first 6 years of life. It is possible that these factors, and others, affect attendance at WCVs more significantly after the first year of life.

The most significant limitations for this study were small sample size and the

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fraction of the patients visiting the UNC Children’s Primary Care Clinic. This makes it challenging to see the power of the factors and covariates that could impact attendance.

Additionally, the insecurities were not screened for at each WCV that patients attended. Most of the insecurities were only screened for once, which does not allow for documentation if a patient’s condition changes over time. This could be crucial for patients whose situation changes over the course of 15 months, or for patients that may not have been screened at all.

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Acknowledgements

This project would not have been possible without the guidance and support of the following individuals.

Morris Weinberger, PhD, Chair of the Department of Health Policy and Management. Dr. Weinberger served as my primary advisor for this project and my advisor throughout my two years in the Health Policy and Management program. I am so thankful for his consistent support and guidance, and I feel so fortunate to have had the opportunity to learn from him.

Dr. Karl Umble, PhD, Assistant Professor and thesis program coordinator. Dr. Umble was my secondary advisor and was extremely helpful throughout this project. I am so thankful for the constant support and advice he provided me throughout this school year. I could not have completed this project without his encouragement, and am so thankful for everything I have learned from him.

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supportive throughout this project and I am so thankful for the opportunity he gave me in allowing me to pursue this research project.

Works Cited

[1] "Social Determinants of Health," 03 12 2019. [Online]. Available:

https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. [2] C. Gundersen and J. P. Ziliak, "Food Insecurity and Health Outcomes," Health Affairs , vol.

34, no. 11, 2015.

[3] "Food Security in the US," United States Department of Agriculture , 4 September 2019. [Online]. Available: https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/measurement.aspx#insecurity. [Accessed 20 November 2019].

[4] D. B. Cutts, A. F. Meyers, M. M. Black, P. H. Casey, M. Chilton, J. T. Cook, J. Geppert, S. Ettinger de Cuba, T. Heeren, S. Coleman, R. Rose-Jacobs and D. A. Frank, "US Housing Insecurity and the Health of Very Young Children," American Journal of Public Health ,

vol. 101, no. 8, pp. 1508-1514, 2011.

[5] P. Martin, W. Liaw, A. Bazemore, A. Jetty, S. Petterson and M. Kushel, "Adults with Housing Insecurity Have Worse Access to Primary and Preventive Care," Journal of the American Board of Family Medicine , vol. 32, no. 4, pp. 521-530, 2019.

[6] "Access to Health Services," Office of Disease Prevention and Health Promotion, 3 December 19. [Online]. Available:

https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services. [Accessed 20 November 2019].

[7] "Well-child visits," MedlinePlus, 6 November 2019. [Online]. Available:

https://medlineplus.gov/ency/article/001928.htm. [Accessed 20 November 2019].

[8] E. R. Wolf, C. J. Hochheimer, R. T. Sabo, J. DeVoe, R. Wasserman, E. Geissal, D. J. Opel, N. Warren, J. Puro, J. O'Neil, J. Pecsok and A. H. Krist, "Gaps in Well-Child Care

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[9] M. A. Moreno, "The Well-Child Visit," Pediatrics, vol. 172, no. 1, p. 104, 2018. [10] S. Abdus and T. M. Selden, "Adherence With Recommended Well-Child Visits Has

Grown, But Large Gaps Persist Among Various Socioeconomic Groups," Health Affairs,

vol. 32, no. 3, 2013.

[11] C. T. Ma, L. Gee and M. B. Kushel, "Associations Between Housing Instability and Food Insecurity With Health Care Access in Low-Income Children," Ambulatory Pediatrics, vol. 8, no. 1, pp. 50-57, 2008.

[12] B. Starfield, "U.S. Child Health: What's Amiss, And What Should Be Done About It?,"

HealthAffairs, vol. 23, no. 5, 2004.

[13] A. Garg, S. Toy, Y. Tripodis, M. Silverstein and E. Freeman, "Addressing Social

Determinants of Health at Well Child Care Visits: A Cluster RCT," Pediatrics, vol. 135, no. 2, 2015.

[14] C. J. Bottino, E. T. Rhodes, C. Kreatsoulas, J. E. Cox and E. W. Fleegler, "Food Insecurity Screening in Pediatric Primary Care: Can Offering Referrals Help Identify Families in Need?," Academic Pediatrics, vol. 17, no. 5, pp. 497-503, 2017.

[15] H. Daniel, S. S. Bornstein and G. C. Kane, "Addressing Social Determinants to Improve Patient Care and Promote Health Equity: An American College of Physicians Position Paper," Annals of Internal Medicine, 2018.

[16] A. J. Bodurtha Smith and A. T. Chien, "Adult-Oriented Health Reform and Children's Insurance and Access to Care: Evidence from Massachusetts Health Reform," Maternal and Child Health Journal, vol. 23, pp. 1008-1024, 2019.

[17] C. Orr, 2019.

[18] E. R. Wolf, J. O'Neil, J. Pecsok, R. S. Etz, D. J. Opel, R. Wasserman and A. H. Krist, "Caregiver and Clinican Perspectives on Missed Well-Child Visits," Annals of Family Medicine, vol. 18, no. 1, pp. 30-34, 2020.

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Appendix I

Study Setting and Population [17]

The study sample will be comprised of patients and families who received their pediatric primary care at the University of North Carolina (UNC) at Chapel Hill Children’s Primary Care Clinic. The UNC Primary Care Clinic is a pediatric continuity clinic serving children from 7 counties in North Carolina. The patient population served by the clinic is ethnically diverse with approximately 33% of the families identifying as Hispanic and 33% of the families identifying as African-American or Black. The clinic serves an economically vulnerable patient population with >70% of the families having public insurance. The UNC Primary Care clinic has integrated social determinants of health screening, including food insecurity screening, into routine well child care. The clinic began reliably recording this information in the electronic medical record beginning 10/2016.

Study Design [17]

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Warehouse (CDW), we will conduct an electronic query to identify all children who had a 2-month well visit at the clinic. Children’s charts will be eligible for review if they had a visit between 6 and 14 weeks of age in which a ICD10 well visit code was applied (Z00.129 or Z00.121). Once charts have been selected for review, the 2-month visit and subsequent well visit progress notes (4, 6, 9, and 12 month well visits) will be manually reviewed. Chart abstraction will be done using REDCap, an electronic data collection system available at UNC. The

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