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The social paediatrics initiative: a RICHER model of primary health care for at risk children and their… Wong, Sabrina T; Lynam, M J; Khan, Koushambhi B; Scott, Lorine; Loock, Christine Oct 4, 2012

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RESEARCH ARTICLE Open AccessThe social paediatrics initiative: a RICHER modelof primary health care for at risk children andtheir familiesSabrina T Wong1,2*, M Judith Lynam1, Koushambhi B Khan1, Lorine Scott3 and Christine Loock4,5AbstractBackground: The Responsive Interdisciplinary Child-Community Health Education and Research (RICHER) initiativeis an intersectoral and interdisciplinary community outreach primary health care (PHC) model. It is beingundertaken in partnership with community based organizations in order to address identified gaps in thecontinuum of health services delivery for ‘at risk’ children and their families. As part of a larger study, this paperreports on whether the RICHER initiative is associated with increased: 1) access to health care for children andfamilies with multiple forms of disadvantage and 2) patient-reported empowerment. This study provides the firstexamination of a model of delivering PHC, using a Social Paediatrics approach.Methods: This was a mixed-methods study, using quantitative and qualitative approaches; it was undertaken inpartnership with the community, both organizations and individual providers. Descriptive statistics, includinglogistic regression of patient survey data (n=86) and thematic analyses of patient interview data (n=7) wereanalyzed to examine the association between patient experiences with the RICHER initiative and parent-reportedempowerment.Results: Respondents found communication with the provider clear, that the provider explained any test results in away they could understand, and that the provider was compassionate and respectful. Analysis of the survey andin-depth interview data provide evidence that interpersonal communication, particularly the provider’s interpersonalstyle (e.g., being treated as an equal), was very important. Even after controlling for parents’ education and ethnicity,the provider’s interpersonal style remained positively associated with parent-reported empowerment (p<0.01).Conclusions: This model of PHC delivery is unique in its purposeful and required partnerships between health careproviders and community members. This study provides beginning evidence that RICHER can better meet the healthand health care needs of people, especially those who are vulnerable due to multiple intersecting socialdeterminants of health. Positive interpersonal communication from providers can play a key role in facilitatingsituations where individuals have an opportunity to experience success in managing their and their family’s health.Keywords: Primary care, Public health, Vulnerable populations, Innovative model, Empowerment, Communityengagement* Correspondence: sabrina.wong@nursing.ubc.ca1University of British Columbia, School of Nursing and Research, 6190Agronomy Road, #302, Vancouver V6T 1Z3BC, Canada2University of British Columbia, Centre for Health Services Policy, #201-2206East Mall, Vancouver V6T-1Z3BC, CanadaFull list of author information is available at the end of the article© 2012 Wong et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Wong et al. BMC Pediatrics 2012, 12:158http://www.biomedcentral.com/1471-2431/12/158BackgroundHealth inequities refer to potentially remedial differ-ences in health or access to care that can result fromstructural arrangements; in this sense, inequities maybe deemed unjust [1]. Indeed, population analysessuggests that health inequalities are magnified due tosocial determinants of health which can lead to in-equitable access to health care [2]. Barriers in acces-sing care can lead to inequities in health for bothadults and children. Even in a country such asCanada that has a universally accessible health caresystem, obtaining needed health care from a regularsource of care varies provincially; approximately 75%of Quebec residents, 88% of British Columbia resi-dents to 93% of Nova Scotia residents report havinga family physician. Although many residents have dif-ficulties in accessing care, families and children whoare made vulnerable by multiple intersecting socialdeterminants of health face both social and structuralchallenges in accessing health care.Inequities in health have become a central concern ofhealth services delivery and health policy in Canada andcountries throughout the world. The World HealthOrganization (WHO) [4] reports that one of the mostefficient ways of “closing the gap” in health inequitieswithin a population is to address the needs of those whoare most disadvantaged. One group who are most disad-vantaged are children living in poverty who are often athigher risk for developmental delay or poor physical ormental health [5,6]. They often miss out on routinescreening and do not benefit from diagnostic assess-ment, treatment and/or early intervention and are athigher risk for needing services from multiple sectorsand/or through a number of developmental stages.When primary health care (PHC) is not accessible or ef-fective, their health may worsen, there is more relianceon emergency care, and they lose the benefits of con-tinuity of care [7,8]. This lack of early recognition andassessment are recognized as posing the greatest threatto child health and wellbeing and as having the greatestnegative impact on children’s health trajectories [9,10].Moreover, past work suggests that families with multipleforms of disadvantage (e.g. poverty, English as a secondlanguage) cannot easily navigate the complexities of thehealth care system, nor always enact recommendedtreatments without additional support [11,12]. It is par-ticularly concerning that the health impact of social andstructural forms of disadvantage are associated withpoor health are cumulative over the life course [13,14].In 2005 researchers mapped the development of allchildren in British Columbia at school entry. The devel-opmental mapping initiative identified that along withbehavioral and learning problems 67.2% of children liv-ing in Vancouver’s inner city entered kindergartendelayed in communication and general knowledge skills[15]. In addition to these developmental profiles, 35% ofchildren in this neighbourhood live in single-parentheaded households and 44% speak English as a secondlanguage [15]. One in five children has parents who areimmigrants, refugees or who are Aboriginal. Each ofthese characteristics has been associated with children’sincreased ‘risk’ for poor health or development.The Responsive Interdisciplinary Child-CoordinatedCommunity Health Education and Research (RICHER)initiative is an intersectoral and interdisciplinary com-munity outreach PHC model. It is being undertaken inpartnership with community based organizations inorder to address identified gaps in the continuum ofhealth services delivery for ‘at risk’ children and theirfamilies. A significant number of children were identifiedas ‘at risk’ because of their developmental profiles andtheir social circumstances. The RICHER initiative seeksto dismantle the structural and social barriers that limitaccess to, and provision of, needed primary and specialtyhealth care services for inner city children who are ‘atrisk’.The RICHER initiative has two main goals. First, itaims to increase access to needed primary health care,public health, and specialist services for children livingin Vancouver’s inner city, who are vulnerable because oftheir social or material circumstances. Second, it aims toempower parents of such children to become more ac-tive participants in the care of themselves and their chil-dren by acquiring knowledge of their child’s healthcondition, knowledge of the resources available to man-age health conditions, and awareness of how to accesssuch resources. As part of a larger study, this paperreports on whether the RICHER initiative is associatedwith increased:1) Access to health care for children and families withmultiple forms of disadvantage; and2) Parent-reported empowermentSocial paediatrics and the RICHER initiativeThe RICHER initiative, informed by social paediatrics, isan intervention that provides access to PHC servicesand, referral for specialized assessments or treatment,while also considering the social conditions that contrib-ute to ‘vulnerabilities’. Social Paediatrics is a philosophyand an approach to practice that locates the child at thecentre of care [16,17]. Providers using a social paediat-rics approach report that it effectively addresses thehealth needs (e.g. developmental and emotional chal-lenges) of children who are disadvantaged because ofintersecting determinants of health and having been vic-tims of violence or abuse. The RICHER initiative uses asocial paediatrics approach [16] to provide services inWong et al. BMC Pediatrics 2012, 12:158 Page 2 of 12http://www.biomedcentral.com/1471-2431/12/158the child’s neighbourhood and, in our case, is under-taken in partnership with community resources; the im-portance of enduring socially supportive relationshipscan mitigate the risk of health inequities for vulnerablechildren [18] and, it is founded on a belief in the compe-tence of children, parents and families. In this case it is a‘best practice approach’ intended to address inequities inchild health. It is informed by insights from the founda-tional work on social paediatrics as articulated by Julien[16]; by related research and practice in communitypaediatrics [19-21] and by Lynam and colleagues’ pro-grams of research with marginalized groups [22-25].Social paediatrics and the RICHER initiative have threecentral premises. First, the social paediatrics approach ispremised on the assumption that the nature of relation-ships built between the health care providers and thechild and his/her family are key to ensuring continuityin service delivery and to ensuring that the parents aresupported and equipped to nurture their child’s develop-ment. In enacting this approach providers seek to createavenues for connection, taking into account the child’sstrengths and abilities in order to tailor care and com-munication in ways that foster the child’s development[17,26]. The social paediatrics approach is not only aninnovative model of PHC service delivery, it serves as amodel for establishing relationships with vulnerable chil-dren and their families to meet their health and develop-mental needs.Second, the social pediatric approach is located in thechild’s community. Providers use interventions that workto strengthen the relationships with providers but alsoto build networks with people who offer a range and di-versity of community-based resources for children andtheir families. The approach seeks to be responsive bytailoring interventions to be timely, supportive, and ef-fective in working with the target population [24,25].The RICHER initiative purposefully partnered withcommunity-based organizations to foster access and ex-tend the types of resources and supports available in-cluding access to resources to address socialdeterminants of health; past work suggests that buildingrelationships through intersectoral collaborations for acommon goal can buffer the negative effects of materialdisadvantage [27-30].Finally, the social paediatrics approach and theRICHER initiative seek to empower both its patients andtheir families to care for their health and well-being. In-dividual families are empowered to care for their health.Empowerment is defined as a process by which peoplegain mastery over their lives [31]. Providers working inthe RICHER initiative try to empower their patients, bysupporting them, guiding them to acquire knowledge oftheir own and their child’s health condition or develop-mental stage, offering strategies for managing theirchild’s health condition and connecting them withresources. Such action encourages patients to assumepersonal responsibility for their health and imparts theidea that what patients do influences their health [32]. Inthe case of RICHER, the providers actively work withprimary caregivers, families and key people in their net-works of support.MethodsDesign and participantsThis was a mixed-methods study that gathered bothquantitative and qualitative data; it was undertaken inpartnership with the community, both organizations andindividual providers. In an effort to undertake researchthat is respectful of peoples’ histories, and to addressquestions identified as priorities within the communitythe broader research study was designed using participa-tory methods [33]. A critical participatory approach toinquiry emphasizes collaboration and reflection and ismarked by features such as reciprocity, inter-subjectivity,reflexivity, and the co-construction of knowledge [34];insights are generated by recognizing and reconcilingmultiple viewpoints. As the study context is a commu-nity with an, often negative, history of ‘surveillance’ byresearchers and practitioners, it was particularly import-ant that the research approaches accorded recognitionto multiple voices and developed strategies to gain anunderstanding of the perspectives of those who havebeen traditionally overlooked in health research. Theorganizations, providers, and research team worked to-gether to articulate the principles of practice and re-search, identify successful data collection methods (bothformat and recruitment procedures), and interpretationof the findings.The site where this study took place was in one ofCanada’s poorest areas, adjacent to Vancouver’s down-town eastside. Most, if not all residents of this area facemultiple forms of disadvantage, including poverty, livingin sub-standard or having no housing, speaking Englishas a second language, a history of mental health pro-blems, and repeated exposure to trauma or violence. Aconvenience sample of eligible participants for this com-ponent of the study were English or Chinese-speaking(Cantonese dialect) families who had used the RICHERprimary care services at least one time in the last 12months. The person in the household that was inter-viewed, on behalf of the child, was his/her main care-giver. Given that the providers deliver many primarycare services in community spaces such as communitycentres and day cares, families were recruited for thisstudy in these areas. Recruitment was also facilitatedthrough the distribution of flyers to the communityspaces and posters in the clinic. Participants received a$15 honorarium in appreciation for their time.Wong et al. BMC Pediatrics 2012, 12:158 Page 3 of 12http://www.biomedcentral.com/1471-2431/12/158In this paper we report on the data gathered using astandardized questionnaire, and unstructured qualitativeinterviews undertaken to engage in a more full explor-ation of individual participants’ responses.ProceduresA combination of face-to-face surveys and in-depthinterviews were completed in either English or Canton-ese. All interviews were conducted over six months:February – August 2010. The survey reflected import-ant dimensions of PHC (e.g. strength of affiliation, ac-cessibility, continuity (informational, relationship andmanagement continuity), interpersonal communica-tion, patient activation) based on our previous work[32,35], sociodemographic characteristics, and healthstatus, and confidence in the health care system. Thedimensions of PHC were measured using a combin-ation of items and scales. All scales and items meas-uring dimensions of PHC were publicly available,except for “NP Knowledge of Child”. If items werepart of a scale, internal consistency reliability wasexamined using Cronbach’s alpha coefficient. Con-struct validity was assessed by examining whether thescales correlated as expected with related scales.Scales had adequate internal consistency reliability.The Interpersonal Processes of Care scales [31], con-sisting of three dimensions (communication, interper-sonal style, and shared decision-making), had aCronbach alpha ranging from 0.64 to 0.76. The NP Know-ledge of Child scale had a Cronbach’s alpha of 0.84. Allinterpersonal scales have shown adequate construct validitywhere they were more highly correlated with each otherthan to other scales [35]. All items and scales have under-gone a rigorous forward-backward translation to ensure se-mantic equivalence [36,37]. A convenience sample ofparent/caregivers of children who had attended the cliniccompleted the surveys.Purposive sampling was used to identify intervieweesfor the qualitative interviews. Based on answers providedfor the survey, potential participants for the in-depthinterviews were asked to participate. Interviewees alsoparticipated because they wanted to expand upon an an-swer they provided for the survey. For example, intervie-wees were asked to elaborate on their responsesregarding their involvement in decision making, howthey perceived their care to be coordinated, and to pro-vide examples of how their primary care experiencesthrough RICHER compared to other primary care clinicsthey had used. In addition, field note data were collectedfrom interviewers’ observations during both the surveyand in-depth interviews [38]. All in-depth interviewswere audio-recorded, where pertinent translated, andtranscribed. All procedures were approved by ourcommunity partners, the University British Columbiaethics board and other jurisdictional review boards.Data analysisData analysis involved a two-staged process. First, weanalyzed the data using standard quantitative or qualita-tive techniques. Univariate and logistic regression ana-lysis of the survey data allowed for an examination ofprimary care experiences associated with patient em-powerment. Our independent variables of interestincluded different dimensions of primary care (seeTable 1): strength of affiliation [13,39] with a usualsource of care, and interpersonal communication (com-munication, shared decision-making, and provider’sinterpersonal style) [40]. Strength of affiliation is anindex based on a series of questions about the place,doctor or Nurse Practitioner that knows the child best,that is most responsible for the child’s health, and thatthe parent usually takes the child to when the child issick. For the purposes of this study, interpersonal com-munication consisted of four scales, Clarity of Commu-nication (In the past 12 months, “How often did yournurse practitioner speak too fast?”, “How often did yournurse practitioner use words that were hard to under-stand?”), Explained Results (In the past 12 months, (Inthe past 12 months, “How often did your Nurse Practi-tioner clearly explain your child’s test results such as X-rays, blood tests or developmental screening tests?”, “Howoften did your Nurse Practitioner clearly explain resultsof your child’s physical exam?”), Shared Decision-Making(In the past 12 months, “How often did you and yournurse practitioner work out a treatment plan together?”,“If there were treatment choices, how often did your nursepractitioner ask if you would like to help decide yourtreatment?”), and Interpersonal Style (In the past 12months, “How often was your nurse practitioner con-cerned about your feelings?”, “How often did your nursepractitioner really respect your child?”, “How often didyour nurse practitioner doctor treat you as an equal?”).Responses to these items ranged from always, usually,sometimes, rarely, and never. The NP knowledge of thechild consisted of three items: “How would you rate yourNurse Practitioner’s knowledge of your child’s entire med-ical history?”, “How would you rate your Nurse Practi-tioner’s knowledge of what worries you most about yourchild’s health?”, and “How would you rate your NursePractitioner’s knowledge of your responsibilities at home,work or school?”. Responses for the NP knowledge ran-ged from excellent, very good, good, fair, and poor.Our dependent variable of interest was patient em-powerment. Empowerment [40] is a six-item likert scalethat asked about how often the SPI provider encouragedthe parent in regard to the child’s health or encouragedthe child about his/her health. For ease of interpretation,Wong et al. BMC Pediatrics 2012, 12:158 Page 4 of 12http://www.biomedcentral.com/1471-2431/12/158Table 1 Experiences of primary careCharacteristics Distribution ormean (N=86)Strength of Affiliation:Strength of Affiliation, grouped (%)No/Weakest affiliation 11.6Weak/Less Strong affiliation 24.4Strong affiliation 64.0Number of times used clinic in past 12months, M (SD)7.2 (10.5)First Contact AccessibilityHow quickly is your child able to see thenurse practitioner when the appointmentyou need is for common health problems? (%)The same day 61.6The next working day 5.8Within 3 or more working days 27.9How quickly has your child been able tosee the Nurse Practitioner when theappointment you need is for an urgent,but minor health problem? (%)The same day 66.3The next working day 11.6Within 3 or more working days 10.4How long do you and your child usuallyhave to wait at your Nurse Practitioner’soffice or place of care from the time of yourappointment until your visit begins? (%)0–10 minutes 61.611–20 minutes 22.121–30 minutes 10.531+ minutes 4.7Experience with Social PaediatricsInitiative (SPI) ClinicIn the past 12 months, has your child’sdevelopment been assessed? (%)Yes 54.7Among those assessed, concerns identified: (%)Speech and Language 23.4Learning 19.1Social/emotional development 17.0Behavioral problems 14.9Other:Physical ability 8.5Vision 4.3Hearing 6.4Among those who had been assessed,was child referred to:Development services 19.8Supported child care or having special needs 20.9SPI provider/team participated in, or helpedyou to organize a meeting to discussabout your child and put in place a plan ofcare with others? (%)Table 1 Experiences of primary care (Continued)Yes 27.9Relationship ContinuitySee the same provider? (%)Always 51.2Usually 30.2Sometimes 9.3Rarely/Never 8.22NP knowledge of child (3 items)M(SD)3 3.9 (1.0)Observed range 1 – 5Cultural ResponsivenessDifficulty getting health care because yourcultural ways were not taken into consideration? (%)Never 46.5Rarely 8.1Sometimes 8.1Usually/Always 1.2Language barriers when trying to get theongoing care that you or your child needed? (%)Never 36.0Rarely 10.5Sometimes 11.6Usually/Always 5.8Communication1Interpersonal Processes of Care (IPC) GeneralClarity of Communication scale (2 items)M (SD) 4.6 (0.6)Observed range: 3 – 51IPC Explained Results scale (2 items)M (SD)4 4.3 (0.9)Observed range 2 – 5Decision Making1IPC Decision Making scale (2 items)M (SD)5 3.7 (1.3)Observed range: 1 – 5How important is it to you to have a NursePractitioner include you in the decision-makingof treatment plans for your child?Not important at all 3.5Somewhat important 16.3Very important 77.9Interpersonal Style1IPC Compassionate, Respectful scale (3 items)M (SD)6 4.7 (0.5)Observed range: 2.7 – 5How important is it to you to have a NursePractitioner that treats you as an equal?Not important at all 0.0Somewhat important 10.5Very important 88.4Wong et al. BMC Pediatrics 2012, 12:158 Page 5 of 12http://www.biomedcentral.com/1471-2431/12/158the Empowerment scale was dichotomized into never/rarely/sometimes (0) and usually/always (1) for the logis-tic regression. The items in the empowerment scalewere: “How often did your Nurse Practitioner: praise youfor how you were taking care of your child’s health? helpyour child feel that sticking with the treatment wouldmake a difference? help your child feel that his/her every-day activities such as diet and lifestyle make a differencein his/her health? help you feel confident about yourability to take care of your child’s health? help you feelthat you have a sense of control over your child’s health?help you feel like you can prevent some of your child’shealth problems?” For all scales, a score was only calcu-lated if at least 60% of the items were answered. All scalescores ranged from 1–5 where a higher score indicatedmore of the construct.In-depth interview/field note data were analyzed usingthematic analysis according to procedures for qualitativedata [41]. Interview transcripts were repeatedly read bythe research team to identify recurring and contradictorypatterns in the data, and links to theoretical work. Acoding scheme was developed for the patient and healthcare provider data. NVivo, a qualitative software pack-age, was used to organize the data. Quality of the datawas ensured by attention to the depth and variation ofthe data gathered [41]. Credibility of the analysis wascontinually evaluated with the research team, whichincluded members of the community organizations andRICHER providers.Second, we performed mixed methods data analyses inorder to a) seek convergence and corroboration ofresults from the different methods and b) achieve com-plementarity where the interview results enhanced andclarified the survey results [42]. For example, the ana-lysis of survey data and the thematic analysis of inter-view data allowed us to compare the participants’ ratingsof ‘access’ to those identified in past research and alsogain a more comprehensive understanding of the com-plexities of ‘access’ and the role of relationships in fos-tering access. We gave equal priority to quantitative andqualitative data and concurrently analyzed the survey andinterview/field note data. Quotes from qualitative data seenin the results section are each from different parents. Wepresent the mixed-method analysis in the results section.ResultsDescription of the sampleA total of 86 respondents completed the survey abouttheir child’s PHC experiences and 8% also completed anin-depth interview. Table 2 shows the characteristics ofthe parents, most of whom were mothers. The mean agewas 37.7 years with over half (54%) being single parenthouseholds and reporting their highest level of educationwas grade 12 or lower (50%). Almost two-thirds of therespondents reported they were either of Chinese (33%)or Aboriginal (29%) heritage. While English was the pre-dominant language spoken at home, half of the respon-dents reported being immigrants to Canada (51%).Fewer than one quarter of the respondents (19%) workedfull time and almost half worked either part-time (15%)or reported they were looking after their home/family(33%). Thirteen percent of parents reported they wereunable to work due to long-term illness or disability. Themajority of household incomes were low with 41% ofrespondents reporting an income range of $10,000-$30,000. Most respondents were renting (81%) and many(43%) reported receiving financial support for housing.Most respondents reported living in a household with4 or more people (57%) where there were one or twochildren. About one-quarter of respondents (27%)reported living in a household where there were three ormore children. The majority of children (82%) attendingRICHER were reported to be in excellent, very good, orgood health. Almost one-quarter of the children (23%)had been diagnosed with a chronic health problem, al-most equally represented by congenital and developmen-tal concerns (e.g. birth defects, fetal alcohol syndrome),autism, and speech and language delay.Parents’ reports of their experiences with RICHERTable 1 shows the survey respondents’ experiences usingRICHER. Parents reported using the clinic an average ofseven times in the last year where 64% reported having astrong affiliation with their usual source of care.Seventy-eight percent of respondents report being ableto access RICHER either the same day or the next work-ing day for urgent, but minor health problems (e.g. skinrash, bed bugs) and 66% report being able to see aRICHER provider within this same time frame for com-mon health problems (e.g. cold and cough). The majority(84%) of respondents reported waiting 20 minutes orless for their scheduled appointment time. Continuity ofcare was provided by seeing the same provider for mostrespondents (81%) and having the provider involved incoordination of care (28%) between RICHER, publicTable 1 Experiences of primary care (Continued)Patient Empowerment1Empowerment Scale (6-items)M (SD)7 4.2 (0.9)Observed range: 2 – 51Potential range of scales are 1–5 where a higher score equals more of theconcept; 5-always, 4-usually, 3-sometimes, 2-rarely, and 1-never. 2Potentialrange of scale was 1–5 where a higher score equals more of the concept;5-excellent, 4-very good, 3-good, 2-fair, 1-poor. 3N=2 missing (2.3%), 4N=42missing (48.8%) because items in the scale were not applicable, 5N=34 missing(39.5%) because items in the scale were not applicable, 6N=1 missing (1.2%),7N=10 missing (11.6%).Note. Frequencies may not add to 100% due to missing data because itemswere not applicable.Wong et al. BMC Pediatrics 2012, 12:158 Page 6 of 12http://www.biomedcentral.com/1471-2431/12/158health, and specialist care, when needed. Importantly,parents reported that the RICHER providers identifiedone in every five children needing further support, in-cluding access to specialized services, from the healthcare system for developmental delays in: speech andTable 2 Characteristics of the sampleCharacteristics of parent who answeredthe survey:Distribution ormean (N=86)Gender of parent (%)Female 91.9Age of parent, M (SD) 37.7 (9.4)Single parent (%)Yes 53.5Marital status (%)Married or living with a partner 47.7Separated/Divorced/Widowed 23.3Never Married 24.4Highest level of education (%)Did not complete secondary school orhigh school26.7Completed secondary school or high school 23.3Had some university education or completed acommunity college, technical college, orpostsecondary program30.2Completed a bachelor’s, graduate orprofessional degree16.3Work status (%)Employed1:Full-time 18.6Part time 15.1Unemployed/looking for work 12.8Looking after your home/family 32.6At school/full-time education2 3.5Unable to work due to a long-termsickness or disability12.8Retired/other 2.3Ethnicity (%)White 23.3Chinese 32.6Aboriginal (First Nations/Metis) 29.1Other (Korean, Latino, Filipino, African,mixed ethnicity)15.1Born in Canada (%)No 51.2For those not born in Canada, # of yearsliving in Canada, M(SD)11.0 (7.6)Range 0–31 yearsLanguage spoken at home (%)English 58.1Cantonese/Mandarin 32.6Other 9.3Total household size (%)1–2 22.13 19.84 25.6≥5 32.6Table 2 Characteristics of the sample (Continued)Number of children < 18 years oldin household (%)0 4.71 39.52 29.13 14.04 or more 12.8Household income (%)Less than $10,000 25.6$10,000 - $30,000 40.7$30,000 - $50,000 11.6$50,000 - $80,000 5.8More than $80,000 3.5Type of housing (%)Apartment 50.0House 44.2Other (e.g. room, basement suite) 5.8Length of time in home, M (SD) 3.8 (3.3) yearsRange ½ month - 15 yearsRent or own? (%)Rent 81.4Own 14.0Other 2.3Receives financial support for housing (%)Yes 43.0Characteristics of the child that the parentfocused on in the Survey:Distribution orMean (N=86)Overall general health (%)Excellent/Very good 51.2Good 31.4Fair/Poor 17.4Diagnosis of long-term or chronichealth problems (%)Yes 23.3For those with long-term or chronic healthproblem(s), number of health problems, M(SD)1.5 (0.7)For those with long-term or chronic healthproblem(s) (%):Developmental (e.g. ADHD, autism,delayed speech)45.0Congenital (e.g. Fetal Alcohol Syndrome) 50.01This refers to employment outside of the home. It also includes self-employment and work training programs.2Includes one parent who gave two answers: ‘at school/in full-time education’and ‘unemployed/looking for work’.Note. Frequencies may not add to 100% due to missing data. There was too muchmissing data to calculate mean age of children. Sex of child was not asked.Wong et al. BMC Pediatrics 2012, 12:158 Page 7 of 12http://www.biomedcentral.com/1471-2431/12/158language (23%), learning (19%), social/emotional (17%),behaviour (15%), other areas such as vision and hearing.The majority of families who reported a child withchronic condition were coping with a developmental ora congenital condition (e.g. congenital heart disease,cerebral palsy, ADHD, autism spectrum disorder, FetalAlcohol Spectrum Disorder) that influenced their child’sdevelopment. The survey data collected from parentsasked that they only report on one of their children whoused RICHER. The interview data provide more context-ual detail; importantly families actually had multiplechildren with a long-term or chronic condition.The following data excerpt enhances the survey resultsby illuminating health inequities are addressed usingRICHER. Thematic analysis suggests that RICER pro-vided opportunities for increased access to specialty careand coordination of care across the system. This parentdiscusses how the RICHER initiative increased access tothe full spectrum of health care services. In this case theprimary care provider has worked with the child in hisenvironment, has assisted the child by fostering accessinto specialized services, and has worked with the parentto foster her understanding of, and her ability to act on,the assessment information.“Parent: Oh, walk in clinics I’ve been there manytimes, but it’s a nightmare. . .because there are a lot ofpeople. I have a problem because my little one isADHD. He’s really hyperactive and then when I comein, it’s really difficult. . ...Interviewer: In your experience have you found that(the nurse practitioner) has responded to yourconcerns? Across all the visits or maybe could yougive an example from one of the visits?Parent: Umm, she just works, as a part of the teamwith the daycare, and to uh, to my son get hispediatrician. . . she just worked hard to try and get myson’s (developmental) assessment to (tertiarycentre). . .. . .. He needed [a] pediatrician, he needed[an] assessment, you know. . .Before him, I was amother to 3 kids, but I never had a little one. . ..he isreally, really energetic. . .. . .. . .For me, it was (one ofthe NPs). She talked to daycare and phoned to socialworker and. . ..all of them I know are working(together).. . ..It’s good, you know to have someoneinterested in your kid’s problem because sometimesyou don’t know what to do. You aren’t a professional.You don’t know what they need.”This parent felt that she gained support for dealing with anumber of health challenges for one of her children andrecognized the need for a referral to mental health servicesfor a 2nd child. In this case the mother identified she neededmore than the episodic care provided at the walk-in clinicsshe had accessed in the past. She also recognized the limitsof their own expertise (e.g. she had limited knowledge ofchild development, limited knowledge of ways to manageher children’s health conditions, and limited knowledge ofhow to navigate the health care system to access appropri-ate health care services).The survey data suggest most respondents did nothave language barriers (58%) in accessing RICHER. Eventhough many families reported speaking languages otherthan English (and many were immigrant families), theyreported high scores on communication with the pro-vider and the provider’s interpersonal style. Respondentsfound the communication clear, that the providerexplained any test results in a way they could under-stand, and that the provider was compassionate and re-spectful. Lower scores were reported for shareddecision-making. Over three-quarters of respondentsreported that both shared decision-making (78%) andprovider’s interpersonal style (88%) (e.g. being treated asan equal) was very important. Respondents scored highon the patient empowerment scale.Another theme across the interview data was the im-portance of interpersonal communication between par-ents and their child’s primary care provider. This nextquote illustrates the importance of being treated withrespect. This parent has four children, one of whom hasmobility, speech language, neurological and develop-mental challenges.“Interviewer: In the past 6 months have you everexperienced difficulty getting health information atthis (RICHER) clinic?Parent: No.Interviewer: What about at your (former) familydoctor?Parent: Yes. The doctors, sometimes the nurses (atthe doctor’s office) aren’t very nice. Sometimes thedoctor’s like arrogant, prideful. Very arrogant like. . ...Sometimes when you ask the nurse something, they’relike arrogant. They say you have to wait.Interviewer: Like they rush you?Parent: Yes.Interviewer: Have you experienced this at this(RICHER) clinic?Parent: No.Wong et al. BMC Pediatrics 2012, 12:158 Page 8 of 12http://www.biomedcentral.com/1471-2431/12/158Interviewer: Okay. When you come to this clinic, doyou feel that (the provider) respected you and yourchildren?Parent: Yes. . .. . ..She’s very nice. Anything she doesshe asks you first for your opinion. The children alsolike her a lot. She usually first talk to the children,play with them a little first.”This parent also emphasized the respectful treatment(of herself and her children) and the benefits of havingthe provider help her understand her health and herchildren’s health challenges.Taken together, the survey and interview data provideevidence that interpersonal communication, particularlyrespect, is related to parent-reported empowerment. Thesurvey data, the univariate and logistic regression resultsare shown in Table 3. Reports of increased interpersonalprocesses of care communication and interpersonal styleand NP knowledge of the child were significantly relatedto empowerment. The univariate results also suggest thatour variables of interest, except for Strength of Affiliationwith a usual source of care, were significantly related toempowerment. However, the logistic regression model sug-gests that after controlling for parents’ education and ethni-city, only the provider’s interpersonal style remainspositively associated with patient empowerment (p<0.01).This result suggests that the relationship with the providercould play an important role in empowering parents whouse RICHER.The last theme found across the interview data was theimportance of relationships that parents have with thehealth care providers. In this case the children are copingwith their own developmental challenges, a situation that iscompounded by the fact that the parent is struggling withmental health issues and recently was injured in an acci-dent. The mother notes that these health challenges are alsocompounded by her immigrant status, lack of fluency inEnglish and her limited income. She reports often feelingmisunderstood and feels alone due to separation fromfriends and family. She relies upon community centreresources for support and to assist her to ensure she has ad-equate food for her family. She also indicates that copingwith these multiple challenges has magnified her feelings ofnot being able to provide for her children. As she explains,she frequently sought help for her own health challengesthrough emergency services.“Parent: And all the people that I called too weren’tthere and I didn’t want to call the crisis line becausethey always misunderstand me in terms of asking forhelp. They think that, I do want to hurt myself butsometimes I just want to talk to someone. Becauselike when you have other languages, when you speakother language maybe you say something that itmeans something else, but they don’t understand.”Table 3 Univariate and logistic regression models for primary care experiences and patient empowerment (N=86)Univariate Demographics & experiencelogistic regression (R2= 0.47)Variable N % Odds ratio Overall p value/CI Odds ratio Overall p value/CIEducation <0.05 NSDid not complete high school or secondary school 22 30.6 0.14 (0.04, 0.55) 0.29 (0.04, 2.26)Completed high school or secondary school 18 25.0 0.37 (0.09, 1.62) 1.04 (0.08, 13.49)At least some college, university or post-secondary 32 44.4 (ref) (ref)Self-reported Ethnicity <0.01 NSWhite/Caucasian/European 15 20.8 (ref) (ref)Chinese 24 33.3 0.13 (0.02, 0.71) 0.98 (0.06, 15.75)Aboriginal (First Nations/Metis) 21 29.2 1.46 (0.18, 11.74) 6.09 (0.21, 174.05)Other 12 16.7 0.46 (0.06, 3.35) 0.92 (0.05, 18.59)Strength of Affiliation NS not included in modelScale range 0 to 4, treated as continuous 0.64 (0.35, 1.20)IPC Communication: Clarity of Communication <0.005 NSScale range 3 to 5, treated as continuous 3.94 (1.64, 9.45) 1.65 (0.46, 5.94)IPC Style: compassionate, respectful <0.0001 <0.01Scale range 2.67 to 5, treated as continuous 34.52 (7.54, 157.93) 20.08 (3.04, 132.59)NP Knowledge of child <0.001 NSScale range 1.67 to 5, treated as continuous 3.46 (1.72, 6.99) 2.43 (0.79, 7.44)Note. Bold indicates statistically significant results. Empowerment was the dependent variable where “never/rarely/sometimes=0, usually/always=1”. NS=notsignificant. IPC communication scales: Elicited Concerns and Shared Decision-making were not included in these models due to high amounts of missing.Wong et al. BMC Pediatrics 2012, 12:158 Page 9 of 12http://www.biomedcentral.com/1471-2431/12/158The interpersonal style of the provider was importantin narrowing the gap in health inequalities since theprovider was able to connect this woman with theresources she needed,“Interviewer: Right. What about the (communitycentre) team?Parent: Yeah, they, the (community centre) team theyhelp me with food, with counselling in terms of myolder son, my teenager, they talk to him. They helpthe little one by putting him in a program here for,that he works, you know, they call, and they help me,talking to me and refer me to places too. And theywere the ones who refer me to the nurses here, so.”For these parents, having someone who cares aboutthem and who knows is knowledgeable of the range ofinfluences on their child and family situations is highlyvaluable.DiscussionThe analyses of these data suggest that the RICHER ini-tiative can provide access to care across the continuumof health care services for children (and their families)who are vulnerable because of their social and materialcircumstances. Health inequities often seen in those whocannot access health care could decrease with the imple-mentation of RICHER. These results provide the firstexamination of an innovative model of delivering PHC,using a Social Paediatrics approach. Respondents weredisproportionately poor, had lower education than theprovincial average, and many had a child or childrenwho had an identified developmental delay or chronichealth condition. This model of PHC delivery is uniquein its partnerships among health care providers andcommunity members. RICHER has also developed anumber of mechanisms for community engagement andpublic participation in order to ensure that there is bothcommunity input about services and accountability onservice delivery to the community [33].These results also provide additional evidence that theinteraction between the provider and patient is an im-portant factor associated with the patient reported out-come measure of empowerment. The provider’sinterpersonal style of compassion and respectfulness waskey to empowering patients to care for their health andthe health of their children. This type of interpersonalstyle likely improves the provider’s and patient’s percep-tions of trust in each other. Mutual trust improves co-operation, reduces the need for monitoring [43] and, inadults is associated with more appropriate prescribing ofopioid analgesics [44]. Past work demonstrates the im-portance of mutual trust [45].Interpersonal communication has been identified as animportant process of care in achieving desirable out-comes of PHC, particularly for those at high risk of pre-mature mortality or morbidity. In this case, childrenliving in the inner city shoulder a disproportionate bur-den of illness and their health challenges are com-pounded by the multiple vulnerabilities and many socialdeterminants of health. Yet, past evidence suggests thatindividualized interventions matched with an individualchild's needs can change a poor health trajectory [46,47].The RICHER initiative is an innovative model of PHCdelivery that: a) facilitates access to programs that affectother social determinants of health such as housing andsupport networks, b) delivers any needed servicesthrough an interprofessional team that includes nursepractitioners and pediatric specialists, and c) is, in part,accountable to the community partners and engagementprocess. Patients, parents and their children, who usethis initiative are empowered to manage their health andthe health of their family because they learn how tonavigate the health care system because of their interac-tions with the RICHER providers and use the network ofsupportive services operated by the community agencies.Given the level of concern for vulnerable populations, andthat the possibility that poor health and developmental out-comes can be averted, the need for support in using appro-priate resources as well as timely referral, diagnosis,treatment, has been underscored in past work [48].The study is not without limitations. Although thissample size captured almost all families using theRICHER initiative at the time the data were being gath-ered, its generalizability is limited given the small samplesize of the survey respondents. Additionally, some ques-tions did contain missing data; Results from the surveyfor these items could be biased to include more respon-dents who had positive experiences. The questionnaireprovided descriptive data about the family but it alsorequired the parent to ‘select’ one child in the familywhen responding to a series of questions. Thus the com-plexity of the family health situation was not always cap-tured. There are a number of social paediatrics centresin various stages of development, in several provinces inCanada. Finally, the interview data are limited by theinterviewee’s ability to carry out open-ended interviews.Notably in Quebec, where the foundational socialpediatric clinics have been established, primary care phy-sicians are used rather than specialists as the point ofentry; nurse practitioners are slowly being introducedinto Quebec. As such the newer centres align moreclosely with the PHC structure of the RICHER initiative.Future work examining patients’ experiences with PHCin this model should include these Canadian sites.Strengths of this study are the mixed methods of datacollection and analyses to provide insight into the waysWong et al. BMC Pediatrics 2012, 12:158 Page 10 of 12http://www.biomedcentral.com/1471-2431/12/158in which vulnerability such as poverty and/or being asingle-parent household with more than one child canbe better understood.ConclusionThis study provides beginning evidence that RICHERcan better meet the health and health care needs ofpeople, especially those who are vulnerable due to mul-tiple intersecting social determinants of health. Positiveinterpersonal communication from providers can play akey role in facilitating situations where individuals havean opportunity to experience success in managing theirand their family’s health. This success can start a processwhereby individuals gain more skills and confidence inmanaging their health. Finally, this type of PHC deliverymodel could positively affect health outcomes by organi-zations and its providers incorporating broad principlesof PHC such as community engagement or public par-ticipation and intersectoral collaboration, particularly forvulnerable populations.Competing interestsNone of the authors have any financial or non-financial competing interests.Authors’ contributionsSW, JL conceived of the study, participated in its design, administered thesurvey, and analyzed the data. KK oversaw the day-to-day operations duringdata collection and analysis. SW, JL, and KK drafted the manuscript. LS andCL facilitated access to the RICHER initiative and participated in theinterpretation of the analysis. All authors were involved in analysis of data. Allauthors read and approved the final manuscript.SupportThis study was supported by the Canadian Institutes for Health Research andthe Michael Smith Foundation for Health Research (Lynam, nominatedprincipal investigator). Dr. Wong was supported by a scholar award from theMichael Smith Foundation for Health Research (CI-SCH-051 (04–1)) and anew investigator award from the Canadian Institutes for Health Research.AcknowledgementsThis research initiative is very much a collaborative effort. We thereforeacknowledge the important role of our institutional and communitypartners: The Provincial Health Services Authority, BC Children’s & Women’sHospital, Vancouver Coastal Health Authority, the Network of East VancouverCommunity Organisations and the Network of Inner City Community ServiceSocieties. We thank the families, community members and providers whoshared their experiences with us. We are particularly grateful to the foundingmembers of the RICHER initiative. We also thank our talented team ofresearch assistants (A. Mann, J. Lui, D. Valenzuela, A. Vittery, A. Huang, H.Sarai) who assisted with recruitment and collecting, entering, and cleaningof data and S. Peterson, who helped with analysis of the survey data. Wetake responsibility for any shortcomings in the analysis and presentation ofpeople’s accounts.Author details1University of British Columbia, School of Nursing and Research, 6190Agronomy Road, #302, Vancouver V6T 1Z3BC, Canada. 2University of BritishColumbia, Centre for Health Services Policy, #201-2206 East Mall, VancouverV6T-1Z3BC, Canada. 3Children’s Hospital, K1-111, 4480 Oak Street, VancouverV6H 3V4BC, Canada. 4Sunny Hill Health Centre for Children, 3644 SlocanStreet, Vancouver V5M 3E8BC, Canada. 5Department of Paediatrics, UBCFaculty of Medicine, 4480 Oak Street, Vancouver V6H 3V4BC, Canada.Received: 28 April 2011 Accepted: 26 September 2012Published: 4 October 2012References1. 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Washington,DC: National Academy Press; 2004.doi:10.1186/1471-2431-12-158Cite this article as: Wong et al.: The social paediatrics initiative: a RICHERmodel of primary health care for at risk children and their families. BMCPediatrics 2012 12:158.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitWong et al. BMC Pediatrics 2012, 12:158 Page 12 of 12http://www.biomedcentral.com/1471-2431/12/158

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