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Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Families
Journal of Pediatric Nursing xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Research Commentary Column
Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Families Becky J. Christian, PhD, RN, FNAP, Professor and PhD Program Director ⁎ School of Nursing, The University of Louisville, Louisville, KY
The intersection between sociocultural and environmental factors and children’s health reflects the powerful influence of social and environmental conditions on the health of children and their families. According to Healthy People 2020 (HHS, 2017), the social determinants of health are comprised of five key components: economic stability, education, social and community context, health and healthcare, as well as neighborhood and built environment. Each of these components influences health outcomes and quality of life for children and their families. When these social and environmental conditions are less than favorable and there is a lack of available resources for children and families, then quality of life is negatively influenced. Moreover, the impact of social and environmental factors on the health of children is magnified among disadvantaged, vulnerable families, thereby creating health disparities. Translation of research evidence generated from nursing research (Polit & Beck, 2017) is designed to provide intervention strategies to improve the quality of nursing care and health outcomes for children and families (Hockenberry & Wilson, 2015; Melnyk & Fineout-Overholt, 2014). Thus, translation of research evidence into pediatric nursing practice improves the health and quality of life of children and families (Christian, 2011, 2013, 2016). Health outcomes are influenced by the complex interrelationships between biology, disease, and sociocultural environments (Horwitz, 2017). Bronfenbrenner’s (2005) bioecological developmental perspective explains how these complex dynamic interactions between multiple systems in the environment contribute to health outcomes of children and their families in the context of their everyday lives. Characteristics of the individual child and family interact with the social and environmental context of home, neighborhood, school and peers, and community. When social and environmental conditions are inadequate with few available resources (e.g., poverty, poor education, unemployment, food and housing instability, lack of transportation, limited access to care, low health literacy, unsafe neighborhoods and environmental conditions), children and families are disadvantaged and vulnerable, thereby creating health disparities that contribute to poor quality of life and health outcomes for children and families (HHS, 2017). Moreover, when children from disadvantaged and vulnerable families have an acute illness or chronic condition, this additional layer of complexity contributes to a greater impact on quality of life. Yet, these social and environmental conditions are modifiable providing the opportunity for ⁎ Corresponding author: Becky J. Christian, PhD, RN, FNAP. E-mail address: [email protected].
interventions designed to improve the overall health and quality of life of children and families. In this issue of the Journal of Pediatric Nursing, 23 articles provide evidence for translation into pediatric nursing practice with respect to a range of social and environmental conditions that influence the health of children and their families, as well as complex chronic conditions and disabilities. These articles highlight the intersection between the social and environmental conditions and health of children and their families, as follows: • A systematic review was employed to identify and evaluate the available pediatric social determinants of health assessment and screening tools (Morone, 2017). A search of the published literature in three online databases (CINAHL, PsycINFO, and PubMed) was conducted and yielded 492 articles with seven additional articles obtained by ancestry search of reference lists resulting in 13 articles that met the inclusion criteria. An evaluation matrix was used to critically appraise and evaluate the literature with respect to the five domains of the social determinants of health as per the Healthy People 2020 guidelines (HHS, 2017). Synthesis of the literature indicated that the majority of screening tools focused on a limited number of the domains of social determinants of health with economic stability as the primary domain assessed. It is important to note that the majority (62%) of the assessment tools identified in this review were not validated and only 30% (n = 4) of the studies employed community members in the initial development of the screening tool. Thus, there is a lack of high quality comprehensive screening tools to assess the social determinants of health risk factors among children and their families. • A secondary analysis of data from a national, ongoing longitudinal study of the Fragile Families and Child Well-Being Study (N = 3301) was conducted at Year-9 follow-up to explore the social determinants of health in 9-to-10 year-old pre-adolescent children to determine the influence of social climate and bullying in elementary school on child health outcomes (Zhang, Padilla, & Kim, 2017). Interviews were conducted in the home with biologic mothers and their 9-to-10 year-old children (52.2% male; 47.8% female). The sample was limited to those who identified as non-Hispanic black (48.3%), Hispanic (29.3%), and non-Hispanic white (22.4%). The overwhelming majority (72.7%) of the children reported excellent to very good health. The majority of children (61.6%) reported experiencing bullying an average of 2.4 times (SD = 3.04) during the past month.
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Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013
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B.J. Christian / Journal of Pediatric Nursing xxx (2017) xxx–xxx
Reports of specific forms of bullying in the last month included: being picked on (51.3%), being purposely left-out of activities (29.75%), being hit (22.6%), and having things taken away from them (12.7%). Of those children who were bullied (61.6%), most reported multiple forms of bullying (20.4% two forms; 14.8% three forms). Both greater frequency of bullying and multiple forms of bullying were associated with lower odds of self-reporting excellent to very good health among children. Children who experienced bullying with peer rejection (being picked on or left-out) were 23.3% less likely to report excellent health as compared to peers; however, children who experienced bullying with physical aggression (hit or having things taken away) did not differ from their peers who were not bullied. Thus, social climate as a social determinant of health measured by bullying at school was found to negatively influence children’s self-reported health status. • A systematic review of the published literature from 2012 to 2017 was employed to explore the mental health of children (ages 0 to 18 years) with respect to access to green space (McCormick, 2017). A search of three electronic databases (Ovid, PubMed, Scopus) yielded nine articles that met the inclusion criteria in addition to three seminal studies published prior to 2012 combined for a total of 12 articles. Access to green space was associated with improved mental well-being, overall health, and cognitive development in children. The restorative effects of access to green space, outdoor play in natural settings, and time spent in nature for children were demonstrated across these studies. Thus, the benefits of access to green space for the mental well-being of children at home and school were supported with implications for the important contributions of the child’s environment for health. • A faith-based and community-based parent training program for Korean American parents was refined in collaboration with community advisory board participants (N = 16) from Korean American Christian churches to promote positive parenting practices and decrease mental health disparities among Korean American children (Kim, Boutain, Kim, Chun, & Im, 2017). The community-based participatory research (CBPR) study was employed to integrate Korean culture and faith into the parenting program to improve the acceptability to Korean American parents. A Delphi survey was used to engage expert community advisory board participants from six Korean American, Christian churches and reach consensus on the mission and structure of the program. Community theater was used to educate participants about the parenting curriculum and integrate Korean cultural values and Christian faith-based principles of living into the program, while focus groups were employed to evaluate the program. Through collaboration with community advisory board participants from Korean American Christian churches, the Korean parenting program was culturally tailored to better reflect Korean culture and Christian faith-based values that were more acceptable to the Korean American Christian faith community to promote the health of minority children living in a different majority culture. • A secondary analysis of data from the 2014 Korean Youth Risk Behavior Web-based Survey representing a national sample of Korean adolescents (N = 3210) from 799 middle schools and high schools (7th to 12th grades) was conducted to explore gender differences in sexual behaviors (Hong & Kang, 2017). A statistically significant difference was found for practicing safe sex with 21.9% males and 17.3% females reporting always practicing safe sex (i.e., always used a condom). For adolescent males, significant predictors of practicing safe sex were higher grade level, smoking, never drinking before sexual intercourse, history of STI, high academic achievement, attending noncoeducational schools, receiving school-based sex education. For adolescent females, significant predictors for practicing safe sex included lower family socioeconomic status, no history of STI, high academic achievement, and being in middle school. Moreover, receiving school-based sex education was not a significant predictor of practicing safe sex among females. Thus, the findings support the
development of gender-specific interventions at the individual, family, and school levels to improve safe sex behaviors and practices among Korean adolescents. • Recommendations for the development of interdisciplinary care clinics for the management of children with disorders/differences of sex development (DSD) are provided to improve the care for children and their families (Bakula et al., 2017). Specific one-year outcome data from an interdisciplinary care clinic for treatment of children with DSD demonstrated that 92% of children met the guidelines of three clinic visits per year. Further, 50% of the children received care from psychiatry or social work, and 58% received nursing education and support during regularly scheduled clinic visits. Importantly, the authors identify the need for the development of comprehensive interdisciplinary care clinics to improve the care and management of the complex physical and psychosocial challenges that children with DSD and their families confront. • A national validation study of the Nursing-Kids Intensity of Care Survey (N-KICS) for pediatric long-term care was conducted to determine construct validity, inter-rater reliability, test–retest reliability, and internal consistency reliability and to test the usability and feasibility of the tool with a sample of children with complex medical conditions (N = 116) across 11 pediatric long-term care (LTC) sites in the U.S. (Hessels, Darby, Simpser, Saiman, & Larson, 2017). Thirty-three nurse (RN) raters participated in the medical record review at two time points using the N-KICS tool with a total of 464 complete surveys (11 missing) from 11 pediatric long-term care sites across all regions of the U.S., including the Northeast (n = 5; 45.5%), South (n = 3; 27.3%), Midwest (n = 2; 18.2%), and West (n = 1; 9%). Inter-rater reliability of the N-KICS tool between the two nurse raters at each LTC site was acceptable for both T1 (r = 0.87, p b 0.05) and T2 (r = 0.89, p b 0.05). Test–retest reliability was acceptable for T1 (r = 0.95, p b 0.05) and T2 (r = 0.97, p b 0.05). The N-KICS tool demonstrated acceptable internal consistency reliability (Cronbach’s alpha N 0.70). Construct validity of the N-KICS tool was established between the nurse managers’ subjective rating of intensity of care needs and nurse clinicians’ objective scored intensity. The N-KICS tool was feasible and easy to use in assessing nursing intensity of care needs for children with complex medical conditions in pediatric LTC settings. Thus, the findings from this study support the reliability and validity of the N-KICS tool in a national sample of children with complex medical conditions in pediatric LTC settings. • A prospective, observational study was conducted with parent caregivers of children with severe cerebral palsy (CP) following orthopedic surgery to determine the impact of non-medical out-of-pocket expenses on their families (Vessey, DiFazio, Strout, & Snyder, 2017). Parents (N = 52) of children with CP (3 to 20 years of age) completed the family expense diary throughout the child’s hospitalization for hip or spine surgery, as well as the financial impact subscale of the Impact on Family Scale and the financial issues subscale of the Assessment of Caregivers Experience with Neuromuscular Disease scale. Results indicated that approximately 30% of the families were classified as in poor or lower middle class poverty levels, with 85% of children receiving federal assistance for their medical expenses. Approximately half of the parents reported that the financial impact of caring for their child represented financial strain for their families and 76.9% of the parents reported that they needed additional income to cover their child’s expenses. The average non-medical out-of-pocket expenses that families incurred during each hospitalization was $2001.92 (SD = 1651.45), accounting for approximately 4% of the families’ annual earned income. The specific non-medical out-ofpocket expenses incurred by families included missed work hours, food expenses, transportation and housing expenses. Regression analysis indicated that parent/caregiver age, income, and distance traveled to the hospital accounted for 32.5% of the variance in non-medical out-of-pocket expenses. Thus, the results of this study highlight the financial burden and significant impact of non-medical out-of-pocket
Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013
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expenses on families of children with severe CP hospitalized for hip or spine surgery. • The conceptual underpinnings of a planned sequential mixed methods study of parents of children and adolescents (b18 years of age) living with type 1 diabetes (T1D) in Ontario, Canada and diabetes nurse educators are described to illustrate the intersection between health policy and the social determinants of health (Visekruna, Hall, Parry, & Spalding, 2017). The Main Determinants of Health framework by Dahlgren and Whitehead (1991) was used to describe the interrelationships between the individual lifestyle factors, social and community networks and socio-economic, cultural and environmental conditions and health policy and equity as applied to T1D care and management. This framework in combination with Lipsky’s (2010) Street level bureaucracy and the four dimensions of control was used to characterize the role of the diabetes nurse educator and the use of assistive devices with respect to health policy and nursing research. These conceptual frameworks have utility in providing guidance for research and health policy development with respect to the social determinants of health. • A community-based participatory research (CBPR) approach was used in an observational study to evaluate the effectiveness of the Dance for Health intergenerational program in increasing access to physical activity in an underserved, high risk urban community (Schroeder et al., 2017). The two-hour, group line dancing sessions were led by trained dance instructors and offered over eight weeks per year from 2012 to 2016 in a neighborhood recreation center. The Dance for Health intervention program was developed in collaboration with the West Philadelphia community school district, schoolbased health center, and an academic institution. Focus groups were conducted to determine participant interest and type of physical activity preferred by parents and children for the intervention program. After baseline data (e.g., age, gender, race, height, weight) were collected, participants were measured weekly for cardiovascular exertion (e.g., heart rate) and perceived exertion at mid-activity and completion of each Dance for Health session. Physical activity was measured as number of steps per pedometer. Program acceptability was evaluated at completion of the intervention program. Data collection was done by high school students mentored by pediatric acute care nurse practitioner students. Over five years, a total of 521 participants (n = 372 adults; n = 149 children, ages 2 to 21 years) attended the program. All of the participants were African American, and the majority (85.8%) were female. Children (50.6%) and adults (80.5%) reached their target heart rate during the dance sessions; both groups perceived their level of cardiovascular exertion as “somewhat hard” although this did not predict likelihood of reaching the target heart rate. Physical activity measured by pedometer steps predicted the likelihood of reaching the target heart rate for adults, but not for children. Changes in adiposity were not found for children or adults. Adults and children rated the program very high for enjoyment and acceptability. Thus, the Dance for Health program was found to demonstrate high levels of community engagement and enjoyment as a culturally appropriate, low cost program for increasing physical activity among children and their families. • A descriptive, cross-sectional quantitative study was conducted to determine how health literacy, race/ethnicity, income, and education influence parents’ underestimations of their child’s weight status (Howe, Alexander, & Stevenson, 2017). A convenience sample of parents (N = 160) of 213 children (7 to 13 years of age) was recruited from those who attended a free family night at a local children’s museum of science and history. A racially and ethnically diverse sample of parents (71.4% White, 16% African American, 5.2% Asian, 7.5% Other) with 32.5% Hispanic and 28.7% Non-White was recruited. The majority of parents (63.6%) were assessed to have adequate health literacy with approximately half (52.2%) of them being college educated and 44.1% with annual incomes over $70,000. Children (ages 7 to 13 years, mean 8.9 years) were classified according to
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weight status: healthy weight (53%), underweight (1.6%), overweight (25.4%) or obese (19.7%). The majority of parents underestimated their child’s weight regardless of actual weight status. Moreover, of the 45.1% of children who were classified as overweight or obese, only 7.5% of their parents correctly classified their weight status. However, no significant associations were found between parent characteristics of health literacy, race/ethnicity, income, and education with parent underestimations of their child’s weight status. A descriptive, cross-sectional quantitative study was employed to compare low-income mothers’ and fathers’ concerns about their young children’s (ages 3 to 10 years of age) weight status (Vollmer & Mobley, 2017). A convenience sample of low-income mothers (n = 30) and fathers (n = 30) was predominantly white (77% mothers; 67% fathers) and non-Hispanic (90% mothers; 93% fathers) and was recruited in a community setting. Eleven (36.7%) of the children were classified as overweight (BMI N 85th to b 95th percentile) or obese (BMI N95th percentile). Mothers’ perceived child weight and concerns about the child’s weight and future weight were not significantly associated with children’s BMI z-scores. However, there were significant associations between fathers’ perceived child weight and BMI z-scores, as well as concerns about the child’s future weight. Low-income fathers were more accurate and concerned than mothers with respect to their perceptions about the child’s weight status and the child’s future weight. Thus, healthcare providers need to provide education relative to children’s weight status for both low-income mothers and fathers. A secondary analysis of anthropometric data for students (N = 20,188) in K, 3rd, and 5th grades from 85 public elementary schools during the 2010–2011 school year in a predominantly Hispanic, large urban school district in the Southwest U.S. was conducted to determine the overweight and obesity rates among children, as well as the association with characteristics of the school, neighborhood, and geographic location (Santos, Huerta, Karki, & Cantarero, 2017). Generalized linear modeling (GLM) was used to analyze the data with respect to the social determinants of overweight and obesity rates by elementary school. The average proportion of overweight children (BMI N 85th percentile) by school was 30% (SD + 7%). Results indicate that the greater proportion (OR 2.4) of Hispanic students in a school was the one significant social determinant in determining the overweight and obesity rates of children in elementary schools. A descriptive qualitative study was conducted to understand parents’ experiences of stress, illness-related challenges, coping behaviors, and adaptation to the stress of caring for their young child with juvenile idiopathic arthritis (JIA) (Yuwen, Lewis, Walker, & Ward, 2017). Family Systems Theory integrated with the Resiliency Model of Family Stress, Adjustment, and Adaptation was used as the conceptual framework that guided the study. Nine parents (eight mothers; one father) from eight families participated in semi-structured, in-depth interviews about their experiences of providing care for their young child (age 2 to 5 years) with JIA. Interview data were analyzed using inductive content analysis and Atlas.ti qualitative analysis software. The core construct describing the parents’ experiences caring for their child with JIA was captured as Struggling in the Dark to Help my Child, as described by six domains: (a) Not knowing; (b) Reaching out in the dark; (c) Feeling my child’s pain; (d) Working out the kinks; (e) Feeling drained by the whole process; and (f) Being hard on the entire household. Thus, as parents struggled with the daily challenges of their child’s JIA, the multiple challenges of this chronic condition consumed their lives and had an impact on the physical and psychosocial health of the family. A review of the published literature from studies conducted in the U.S. or Canada that focused on the sociocultural factors that influence health outcomes for children with juvenile arthritis (JA) diagnosed prior to age 16 years was conducted using five electronic databases (PubMed, CINAHL, JSTOR, Web of Science, and PsycINFO) (Lewis,
Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013
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Brown, Tiziani, & Carrasco, 2017). The search yielded 46 articles that were reduced to a total of 16 articles that met the inclusion criteria. The five categories of social determinants of health, including biology, individual behaviors, social environment, physical environment, and health services, were used to organize the findings from this review. Child participants with JA across these studies were predominantly female and school-age children. Individual behaviors in the studies focused on physical activity/leisure, dietary modifications, psychosocial functioning, and vocational aspirations of children with JA. Social environment factors included race/ethnicity, psychosocial functioning, parental education level, child education level, and socioeconomic status/income. With respect to race/ethnicity of the samples across studies, 83.1% of the combined sample with JA was white, while three studies specifically focused on a minority samples. Physical environment was assessed in only two of the studies. Health services and insurance status were addressed in six studies. Taken together, the results of this review indicate that health disparities exist for children with JA of racial/ethnic minorities and low socioeconomic status. • An integrative review of the published literature was conducted using five electronic databases (CINAHL, Medline, PubMed, ScienceDirect, and PsycINFO) to determine barriers to addressing the psychological and social determinants of health in pediatric nursing practice with respect to children with chronic conditions or serious illnesses (Tallon, Kendall, Priddis, Newall, & Young, 2017). A total of 13 articles met the inclusion criteria and were evaluated for quality of evidence. Analysis of the literature indicated that healthcare providers identified specific barriers to addressing psychosocial issues among children with chronic conditions or serious illnesses and their families as the dominant use of the medical model of care with the primary focus on disease and treatment, rather than family-centered care. Although healthcare providers empathized with children and their families, they identified the lack of time, the perception that families prioritized physical care in contrast to psychosocial care, and the lack of confidence in healthcare providers’ communication skills to address psychosocial issues as barriers that prevented them from addressing the psychosocial and social issues influencing the health of children and their families. • An explanatory sequential mixed methods design was used to explore the impact of sleep problems on resilience in families of children with autism spectrum disorder (Roberts, Hunter, & Cheng, 2017). Mothers (N = 70) of children with autism spectrum disorder completed the quantitative survey about family resilience and children’s sleep habits. In-depth, qualitative interviews were conducted with six parents (five mothers and one father of five children) who reported that their child had sleep problems. Survey results indicated that parents of children with autism spectrum disorder with sleep problems reported significantly higher levels of family strains and family distress and significantly lower levels of resilience as compared to children who slept well. Regression analysis identified significant predictors of hardiness as greater social support, greater copingcoherence (stress management), and lower strain scores. Qualitative interviews revealed the parents’ views about how they have adapted to the child’s autism spectrum disorder and sleep problems, as captured by the overall theme, Journey toward Family Resilience, with six subthemes: (a) Finding the Trailhead; (b) Dual Pathways; (c) Crossing Paths and Choosing Travel Companions; (d) Forging New Paths; (e) Resting Along the Way; and (f) Seeing the Vistas. Thus, the integrated findings confirmed that families of children with autism spectrum disorder who had better sleep demonstrated more resilience as they adapted to their child’s chronic condition. • A descriptive qualitative study was used to explore the perspectives of mothers of infants with complex congenital heart disease with respect to coping with the stress of hospitalization in the cardiac intensive care unit (CICU), as well as to determine the acceptability and feasibility of mindfulness as a potential intervention for stress reduction (Golfenshtein, Deatrick, Lisanti, & Medoff-Cooper, 2017). Three focus
groups were conducted with mothers (N = 14) of infants with complex congenital heart disease hospitalized in the cardiac intensive care unit. Data analysis was conducted using content analysis and Atlas.ti qualitative analysis software. The majority (n = 13, 93%) of mothers were non-Hispanic white. Mothers described their experiences during the post-diagnostic period, surgery, and the CICU stay as extremely stressful. Mothers used both active and passive coping strategies, but their primary coping mechanism was emotion regulation, rather than problem-solving. Coping strategies were identified as: (a) seeking support systems, (b) positive thinking, (c) focus on the baby, (d) denial, and (e) distraction. Mindfulness as an active coping intervention strategy for stress reduction was introduced to the mothers at the end of the focus group sessions to determine acceptability and feasibility. These mothers expressed mixed reactions to the mindfulness intervention, although they found the mindfulness intervention to be acceptable and feasible for stress reduction. In addition, mothers identified potential barriers to implementation of the mindfulness intervention in the CICU. Thus, this study demonstrated that mothers of infants hospitalized in the CICU utilized emotion regulation as their primary coping strategy. • The usefulness of sociological conceptual frameworks is proposed for better understanding of sudden unexpected deaths in infancy among socially disadvantaged and vulnerable families (Shipstone, Young, & Kearney, 2017). It is important to note that the risk factors associated with socially disadvantaged families increase the risk for sudden unexpected deaths in infancy and reflect the broader social and economic conditions in which families live. Thus, it is critical to consider how these socioeconomic gradients influence sudden unexpected deaths in infancy and interact with biological and physiological factors, physical and social environment, as well as components of the healthcare delivery system. Thus, the authors recommend that researchers and healthcare providers utilize sociological frameworks and principles of behavioral economics to better understand socially disadvantaged and vulnerable families within a broader social and cultural context in order to reduce the risk for sudden unexpected deaths in infancy. • An integrative review was conducted to examine the published literature on chronic sorrow among parents of children with a chronic illness or disability from 1981 to 2015 (Coughin & Sethares, 2017). Of the 59 articles retrieved through a search of five online databases (CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and SocINDEX), 19 articles met the inclusion criteria to address the research questions. Articles were critically appraised for methodological rigor and a review matrix was developed. Eleven studies used a qualitative design, four employed a quantitative design, and four used a mixed methods approach. Findings across these studies indicated that the mothers experienced greater intensity of chronic sorrow about their child’s chronic illness or disability as compared to fathers. Moreover, mothers’ sorrow was permanent, while fathers were able to resolve their grief. Helpful strategies for parents to cope with chronic sorrow were identified and included the need for healthcare providers to demonstrate empathy and compassion for parents, and to provide information and explanations about their child’s condition, treatment and management, resources, and respite care. Parents reported unhelpful strategies by healthcare providers included poor communication, not listening to parents, conflicting information, inadequate time to learn care management, and lack of resources. Thus, chronic sorrow in parents is a consequence of chronic illness or disability in children. • A randomized controlled trial (RCT) was conducted in Turkey to determine the effectiveness of covering the eyes versus playing intrauterine sounds on premature infants’ pain and physiological parameters during venipuncture when compared to premature infants who did not receive the intervention (control) (Alemdar & Özdemir, 2017). Premature infants (N = 94) born at 28th to 36th gestational week were randomly assigned to one of three groups: covered eyes (n = 32), intrauterine sounds (n = 32), and control (n = 30). Statistically significant differences in level of pain after venipuncture were found
Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013
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for premature infants in the covered eyes and intrauterine sounds intervention groups (p b 0.05). However, no significant differences between groups were found for physiological parameters of heart rate or SO2 levels after venipuncture. Thus, covering the eyes and playing intrauterine sounds for premature infants were effective in reducing pain during venipuncture procedures. • A prospective randomized controlled trial (RCT) was conducted to compare the effectiveness of EMLA® with the J-Tip Needleless Injection System® in reducing children’s fear and pain associated with venipuncture for IV insertion (Stoltz & Manworren, 2017). Children (N = 150, ages 8 to 18 years) in the pre-operative suite were randomly assigned to EMLA® or J-Tip® intervention groups prior to IV insertion. Results indicated that children in the EMLA® group had significantly lower average self-reported pain scores as compared to those in the J-Tip® group (p b 0.001), and also had lower VAS pain scores. No significant differences in the levels of children’s fear were found between the EMLA® group and the J-Tip® group over time. Thus, the EMLA® intervention was found to be more effective in reducing the pain associated with venipuncture for IV insertion as compared to J-Tip® intervention. However, the authors noted that because there is a 60min wait time for EMLA to be effective, the clinical situation may require a more rapid treatment such as the J-Tip Needleless Injection System® to prevent IV insertion pain. • A cross-sectional survey was employed to describe nurses’ perceptions of the quality of care for children in Emergency Departments in Finland (Janjunen, Kankkunen, & Kvist, 2017). Nurses (N = 147) from four public Finnish hospitals with either pediatric emergency departments or general emergency departments that served adults and children were surveyed to evaluate the quality of care for pediatric patients. On average nurses had 7.7 years of emergency department experience, with a range of 0 to 15 years of experience in emergency care, and 64% worked in a general emergency department. Nurses rated the quality of professional practice in emergency departments to be high. Nurses in pediatric emergency departments had more positive evaluations of the quality of care for children higher than nurses from general emergency departments. Predictors of greater nursing satisfaction with the quality of pediatric care in emergency departments included higher levels of professional practice, more interdisciplinary collaboration, and adequate human resources. Thus, the quality of pediatric care in emergency departments as evaluated by nurses was related to the nurses’ professional practice.
As highlighted by these articles, it is essential for pediatric nurses to recognize the importance of the intersection between sociocultural and environmental contextual factors and the influence on health outcomes for children and their families. This interaction is especially significant for disadvantaged, vulnerable families and their children. To that end, intervention efforts need to address these interactions between sociocultural and environmental factors that influence health outcomes to improve the quality of care and health outcomes for children and their families. References Alemdar, D. K., & Özdemir, F. K. (2017). Effects of covering the eyes versus playing intrauterine sounds on premature infants’ pain and physiological parameters during venipuncture. Journal of Pediatric Nursing, 31 [XXX]. Bakula, D. M., Sharkey, C. M., Wolfe-Christensen, C., Mullins, A. J., Meyer, J., Mullins, L. L., & Wisniewski, A. B. (2017). Recommendations for the establishment of disorders/differences of sex development interdisciplinary care clinics for youth. Journal of Pediatric Nursing, 31 [XXX]. Bronfenbrenner, U. (2005). The bioecological theory of human development. In U. Bronfenbrenner (Ed.), Making human beings human: Bioecological perspectives on human development. Thousand Oaks, CA: Sage.
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Christian, B. J. (2011). Hallmark of excellence: Research and evidence-based practice as the foundation for quality pediatric nursing. Journal of Pediatric Nursing, 26, 170–171. Christian, B. J. (2013). Translational research — The imperative for integrating evidence into pediatric nursing practice to improve health outcomes. Journal of Pediatric Nursing, 28, 508–510. Christian, B. J. (2016). Translational research — New evidence for guiding intervention development to improve the lives of children and their families. Journal of Pediatric Nursing, 31, 214–216. Coughin, M. B., & Sethares, K. A. (2017). Chronic sorrow in parents of children with a chronic illness or disability: An integrative review. Journal of Pediatric Nursing, 31 [XXX]. Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health. Stockholm, Sweden: Institute for Future Studies [Available at: http://www. iffs.se/media/1326/20080109109110739filmZ8UVQv2wQFShMRF6cuT.pdf]. Golfenshtein, N., Deatrick, J. A., Lisanti, A. J., & Medoff-Cooper, B. (2017). Coping with the in the cardiac intensive care unit: Can mindfulness be the answer? Journal of Pediatric Nursing, 31 [XXX]. Hessels, A. J., Darby, S. W., Simpser, E., Saiman, L., & Larson, E. L. (2017). National testing of the Nursing-Kids Intensity of Care Survey for pediatric long-term care. Journal of Pediatric Nursing, 31 [XXX]. Hockenberry, M. J., & Wilson, D. (2015). Wong's nursing care of infants and children (10th Ed.). St. Louis: Mosby. Hong, E., & Kang, Y. (2017). Gender differences in sexual behaviors in Korean adolescents. Journal of Pediatric Nursing, 31 [XXX]. Horwitz, A. V. (2017). Social context, biology, and the definition of disorder. Journal of Health and Social Behavior, 58, 131–145. https://doi.org/10.1177/0022146517705165. Howe, C. J., Alexander, G., & Stevenson, J. (2017). Parents’ underestimations of child weight: Implications for obesity prevention. Journal of Pediatric Nursing, 31 [XXX]. Janjunen, K., Kankkunen, P., & Kvist, T. (2017). Nursing staffs’ perceptions of quality of care for children in emergency departments — High respect, low resources. Journal of Pediatric Nursing, 31 [XXX]. Kim, E., Boutain, D., Kim, S., Chun, J. -J., & Im, H. (2017). Integrating faith-based and community-based participatory research approaches to adapt the Korean parent training program. Journal of Pediatric Nursing, 31 [XXX]. Lewis, K. A., Brown, S. A., Tiziani, S., & Carrasco, R. (2017). Sociocultural considerations in juvenile arthritis: A review. Journal of Pediatric Nursing, 31 [XXX]. Lipsky, M. (2010). Street level bureaucracy — Dilemmas of the individual in public services. New York, NY: Russell Sage Foundation. McCormick, R. (2017). Does access to green space impact the mental well-being of children: A systematic review. Journal of Pediatric Nursing, 31 [XXX]. Melnyk, B. M., & Fineout-Overholt, E. (2014). Making the case for evidence-based practice and cultivating a spirit of inquiry. In B. M. Melnyk, & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing and healthcare: A guide to best practice (pp. 3–24) (3rd Ed.). Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins. Morone, J. (2017). An integrative review of social determinants of health assessment and screening tools used in pediatrics. Journal of Pediatric Nursing, 31 [XXX]. Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th Ed.). Philadelphia: Lippincott Williams & Wilkins. Roberts, C. A., Hunter, J., & Cheng, A. -L. (2017). Resilience in families of children with autism and sleep problems. Journal of Pediatric Nursing, 31 [XXX]. Santos, R., Huerta, G., Karki, M., & Cantarero, A. (2017). Social determinants of overweight and obesity rates by elementary school in a predominantly Hispanic school district. Journal of Pediatric Nursing, 31 [XXX]. Schroeder, K., Ratcliffe, S. J., Perez, A., Earley, D., Bowman, C., & Lipman, T. H. (2017). Dance for health: An intergenerational program to increase access to physical activity. Journal of Pediatric Nursing, 31 [XXX]. Shipstone, R., Young, J., & Kearney, L. (2017). New frameworks for understanding sudden unexpected deaths in infancy (SUDI) in socially vulnerable families. Journal of Pediatric Nursing, 31 [XXX]. Stoltz, P., & Manworren, R. C. B. (2017). Comparison of children’s venipuncture fear and pain: Randomized controlled trial of EMLA® and J-Tip Needleless Injection System®. Journal of Pediatric Nursing, 31 [XXX]. Tallon, M. M., Kendall, G. E., Priddis, L., Newall, F., & Young, J. (2017). Barriers to addressing social determinants of health in pediatric nursing practice: An integrative review. Journal of Pediatric Nursing, 31 [XXX]. U.S. Department of Health and Human Services (HHS) (2017). Healthy People 2020, social determinants of health. Retrieved from: https://healthypeople.gov/2020/ topics-objectives/topic/social-determinants-of-health. Vessey, J. A., DiFazio, R. L., Strout, T. D., & Snyder, B. D. (2017). Impact of non-medical outof-pocket expenses on families of children with cerebral palsy following orthopaedic surgery. Journal of Pediatric Nursing, 31 [XXX]. Visekruna, S., Hall, L. M., Parry, M., & Spalding, K. (2017). Intersecting health policy and the social determinants of health in pediatric type 1 diabetes management and care. Journal of Pediatric Nursing, 31 [XXX]. Vollmer, R. L., & Mobley, A. R. (2017). Comparing low-income mothers’ and fathers’ concerns for young children’s weight status. Journal of Pediatric Nursing, 31 [XXX]. Yuwen, W., Lewis, F. M., Walker, A. J., & Ward, T. M. (2017). Struggling in the dark to help my child: Parents’ experience in caring for a young child with juvenile idiopathic arthritis. Journal of Pediatric Nursing, 31 [XXX]. Zhang, A., Padilla, Y. C., & Kim, Y. (2017). How early do social determinants of health begin to operate? Results from the Fragile Families and Child Well-being Study. Journal of Pediatric Nursing, 31 [XXX].
Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013
Contents lists available at ScienceDirect
Journal of Pediatric Nursing
Research Commentary Column
Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Families Becky J. Christian, PhD, RN, FNAP, Professor and PhD Program Director ⁎ School of Nursing, The University of Louisville, Louisville, KY
The intersection between sociocultural and environmental factors and children’s health reflects the powerful influence of social and environmental conditions on the health of children and their families. According to Healthy People 2020 (HHS, 2017), the social determinants of health are comprised of five key components: economic stability, education, social and community context, health and healthcare, as well as neighborhood and built environment. Each of these components influences health outcomes and quality of life for children and their families. When these social and environmental conditions are less than favorable and there is a lack of available resources for children and families, then quality of life is negatively influenced. Moreover, the impact of social and environmental factors on the health of children is magnified among disadvantaged, vulnerable families, thereby creating health disparities. Translation of research evidence generated from nursing research (Polit & Beck, 2017) is designed to provide intervention strategies to improve the quality of nursing care and health outcomes for children and families (Hockenberry & Wilson, 2015; Melnyk & Fineout-Overholt, 2014). Thus, translation of research evidence into pediatric nursing practice improves the health and quality of life of children and families (Christian, 2011, 2013, 2016). Health outcomes are influenced by the complex interrelationships between biology, disease, and sociocultural environments (Horwitz, 2017). Bronfenbrenner’s (2005) bioecological developmental perspective explains how these complex dynamic interactions between multiple systems in the environment contribute to health outcomes of children and their families in the context of their everyday lives. Characteristics of the individual child and family interact with the social and environmental context of home, neighborhood, school and peers, and community. When social and environmental conditions are inadequate with few available resources (e.g., poverty, poor education, unemployment, food and housing instability, lack of transportation, limited access to care, low health literacy, unsafe neighborhoods and environmental conditions), children and families are disadvantaged and vulnerable, thereby creating health disparities that contribute to poor quality of life and health outcomes for children and families (HHS, 2017). Moreover, when children from disadvantaged and vulnerable families have an acute illness or chronic condition, this additional layer of complexity contributes to a greater impact on quality of life. Yet, these social and environmental conditions are modifiable providing the opportunity for ⁎ Corresponding author: Becky J. Christian, PhD, RN, FNAP. E-mail address: [email protected].
interventions designed to improve the overall health and quality of life of children and families. In this issue of the Journal of Pediatric Nursing, 23 articles provide evidence for translation into pediatric nursing practice with respect to a range of social and environmental conditions that influence the health of children and their families, as well as complex chronic conditions and disabilities. These articles highlight the intersection between the social and environmental conditions and health of children and their families, as follows: • A systematic review was employed to identify and evaluate the available pediatric social determinants of health assessment and screening tools (Morone, 2017). A search of the published literature in three online databases (CINAHL, PsycINFO, and PubMed) was conducted and yielded 492 articles with seven additional articles obtained by ancestry search of reference lists resulting in 13 articles that met the inclusion criteria. An evaluation matrix was used to critically appraise and evaluate the literature with respect to the five domains of the social determinants of health as per the Healthy People 2020 guidelines (HHS, 2017). Synthesis of the literature indicated that the majority of screening tools focused on a limited number of the domains of social determinants of health with economic stability as the primary domain assessed. It is important to note that the majority (62%) of the assessment tools identified in this review were not validated and only 30% (n = 4) of the studies employed community members in the initial development of the screening tool. Thus, there is a lack of high quality comprehensive screening tools to assess the social determinants of health risk factors among children and their families. • A secondary analysis of data from a national, ongoing longitudinal study of the Fragile Families and Child Well-Being Study (N = 3301) was conducted at Year-9 follow-up to explore the social determinants of health in 9-to-10 year-old pre-adolescent children to determine the influence of social climate and bullying in elementary school on child health outcomes (Zhang, Padilla, & Kim, 2017). Interviews were conducted in the home with biologic mothers and their 9-to-10 year-old children (52.2% male; 47.8% female). The sample was limited to those who identified as non-Hispanic black (48.3%), Hispanic (29.3%), and non-Hispanic white (22.4%). The overwhelming majority (72.7%) of the children reported excellent to very good health. The majority of children (61.6%) reported experiencing bullying an average of 2.4 times (SD = 3.04) during the past month.
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Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013
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Reports of specific forms of bullying in the last month included: being picked on (51.3%), being purposely left-out of activities (29.75%), being hit (22.6%), and having things taken away from them (12.7%). Of those children who were bullied (61.6%), most reported multiple forms of bullying (20.4% two forms; 14.8% three forms). Both greater frequency of bullying and multiple forms of bullying were associated with lower odds of self-reporting excellent to very good health among children. Children who experienced bullying with peer rejection (being picked on or left-out) were 23.3% less likely to report excellent health as compared to peers; however, children who experienced bullying with physical aggression (hit or having things taken away) did not differ from their peers who were not bullied. Thus, social climate as a social determinant of health measured by bullying at school was found to negatively influence children’s self-reported health status. • A systematic review of the published literature from 2012 to 2017 was employed to explore the mental health of children (ages 0 to 18 years) with respect to access to green space (McCormick, 2017). A search of three electronic databases (Ovid, PubMed, Scopus) yielded nine articles that met the inclusion criteria in addition to three seminal studies published prior to 2012 combined for a total of 12 articles. Access to green space was associated with improved mental well-being, overall health, and cognitive development in children. The restorative effects of access to green space, outdoor play in natural settings, and time spent in nature for children were demonstrated across these studies. Thus, the benefits of access to green space for the mental well-being of children at home and school were supported with implications for the important contributions of the child’s environment for health. • A faith-based and community-based parent training program for Korean American parents was refined in collaboration with community advisory board participants (N = 16) from Korean American Christian churches to promote positive parenting practices and decrease mental health disparities among Korean American children (Kim, Boutain, Kim, Chun, & Im, 2017). The community-based participatory research (CBPR) study was employed to integrate Korean culture and faith into the parenting program to improve the acceptability to Korean American parents. A Delphi survey was used to engage expert community advisory board participants from six Korean American, Christian churches and reach consensus on the mission and structure of the program. Community theater was used to educate participants about the parenting curriculum and integrate Korean cultural values and Christian faith-based principles of living into the program, while focus groups were employed to evaluate the program. Through collaboration with community advisory board participants from Korean American Christian churches, the Korean parenting program was culturally tailored to better reflect Korean culture and Christian faith-based values that were more acceptable to the Korean American Christian faith community to promote the health of minority children living in a different majority culture. • A secondary analysis of data from the 2014 Korean Youth Risk Behavior Web-based Survey representing a national sample of Korean adolescents (N = 3210) from 799 middle schools and high schools (7th to 12th grades) was conducted to explore gender differences in sexual behaviors (Hong & Kang, 2017). A statistically significant difference was found for practicing safe sex with 21.9% males and 17.3% females reporting always practicing safe sex (i.e., always used a condom). For adolescent males, significant predictors of practicing safe sex were higher grade level, smoking, never drinking before sexual intercourse, history of STI, high academic achievement, attending noncoeducational schools, receiving school-based sex education. For adolescent females, significant predictors for practicing safe sex included lower family socioeconomic status, no history of STI, high academic achievement, and being in middle school. Moreover, receiving school-based sex education was not a significant predictor of practicing safe sex among females. Thus, the findings support the
development of gender-specific interventions at the individual, family, and school levels to improve safe sex behaviors and practices among Korean adolescents. • Recommendations for the development of interdisciplinary care clinics for the management of children with disorders/differences of sex development (DSD) are provided to improve the care for children and their families (Bakula et al., 2017). Specific one-year outcome data from an interdisciplinary care clinic for treatment of children with DSD demonstrated that 92% of children met the guidelines of three clinic visits per year. Further, 50% of the children received care from psychiatry or social work, and 58% received nursing education and support during regularly scheduled clinic visits. Importantly, the authors identify the need for the development of comprehensive interdisciplinary care clinics to improve the care and management of the complex physical and psychosocial challenges that children with DSD and their families confront. • A national validation study of the Nursing-Kids Intensity of Care Survey (N-KICS) for pediatric long-term care was conducted to determine construct validity, inter-rater reliability, test–retest reliability, and internal consistency reliability and to test the usability and feasibility of the tool with a sample of children with complex medical conditions (N = 116) across 11 pediatric long-term care (LTC) sites in the U.S. (Hessels, Darby, Simpser, Saiman, & Larson, 2017). Thirty-three nurse (RN) raters participated in the medical record review at two time points using the N-KICS tool with a total of 464 complete surveys (11 missing) from 11 pediatric long-term care sites across all regions of the U.S., including the Northeast (n = 5; 45.5%), South (n = 3; 27.3%), Midwest (n = 2; 18.2%), and West (n = 1; 9%). Inter-rater reliability of the N-KICS tool between the two nurse raters at each LTC site was acceptable for both T1 (r = 0.87, p b 0.05) and T2 (r = 0.89, p b 0.05). Test–retest reliability was acceptable for T1 (r = 0.95, p b 0.05) and T2 (r = 0.97, p b 0.05). The N-KICS tool demonstrated acceptable internal consistency reliability (Cronbach’s alpha N 0.70). Construct validity of the N-KICS tool was established between the nurse managers’ subjective rating of intensity of care needs and nurse clinicians’ objective scored intensity. The N-KICS tool was feasible and easy to use in assessing nursing intensity of care needs for children with complex medical conditions in pediatric LTC settings. Thus, the findings from this study support the reliability and validity of the N-KICS tool in a national sample of children with complex medical conditions in pediatric LTC settings. • A prospective, observational study was conducted with parent caregivers of children with severe cerebral palsy (CP) following orthopedic surgery to determine the impact of non-medical out-of-pocket expenses on their families (Vessey, DiFazio, Strout, & Snyder, 2017). Parents (N = 52) of children with CP (3 to 20 years of age) completed the family expense diary throughout the child’s hospitalization for hip or spine surgery, as well as the financial impact subscale of the Impact on Family Scale and the financial issues subscale of the Assessment of Caregivers Experience with Neuromuscular Disease scale. Results indicated that approximately 30% of the families were classified as in poor or lower middle class poverty levels, with 85% of children receiving federal assistance for their medical expenses. Approximately half of the parents reported that the financial impact of caring for their child represented financial strain for their families and 76.9% of the parents reported that they needed additional income to cover their child’s expenses. The average non-medical out-of-pocket expenses that families incurred during each hospitalization was $2001.92 (SD = 1651.45), accounting for approximately 4% of the families’ annual earned income. The specific non-medical out-ofpocket expenses incurred by families included missed work hours, food expenses, transportation and housing expenses. Regression analysis indicated that parent/caregiver age, income, and distance traveled to the hospital accounted for 32.5% of the variance in non-medical out-of-pocket expenses. Thus, the results of this study highlight the financial burden and significant impact of non-medical out-of-pocket
Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013
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expenses on families of children with severe CP hospitalized for hip or spine surgery. • The conceptual underpinnings of a planned sequential mixed methods study of parents of children and adolescents (b18 years of age) living with type 1 diabetes (T1D) in Ontario, Canada and diabetes nurse educators are described to illustrate the intersection between health policy and the social determinants of health (Visekruna, Hall, Parry, & Spalding, 2017). The Main Determinants of Health framework by Dahlgren and Whitehead (1991) was used to describe the interrelationships between the individual lifestyle factors, social and community networks and socio-economic, cultural and environmental conditions and health policy and equity as applied to T1D care and management. This framework in combination with Lipsky’s (2010) Street level bureaucracy and the four dimensions of control was used to characterize the role of the diabetes nurse educator and the use of assistive devices with respect to health policy and nursing research. These conceptual frameworks have utility in providing guidance for research and health policy development with respect to the social determinants of health. • A community-based participatory research (CBPR) approach was used in an observational study to evaluate the effectiveness of the Dance for Health intergenerational program in increasing access to physical activity in an underserved, high risk urban community (Schroeder et al., 2017). The two-hour, group line dancing sessions were led by trained dance instructors and offered over eight weeks per year from 2012 to 2016 in a neighborhood recreation center. The Dance for Health intervention program was developed in collaboration with the West Philadelphia community school district, schoolbased health center, and an academic institution. Focus groups were conducted to determine participant interest and type of physical activity preferred by parents and children for the intervention program. After baseline data (e.g., age, gender, race, height, weight) were collected, participants were measured weekly for cardiovascular exertion (e.g., heart rate) and perceived exertion at mid-activity and completion of each Dance for Health session. Physical activity was measured as number of steps per pedometer. Program acceptability was evaluated at completion of the intervention program. Data collection was done by high school students mentored by pediatric acute care nurse practitioner students. Over five years, a total of 521 participants (n = 372 adults; n = 149 children, ages 2 to 21 years) attended the program. All of the participants were African American, and the majority (85.8%) were female. Children (50.6%) and adults (80.5%) reached their target heart rate during the dance sessions; both groups perceived their level of cardiovascular exertion as “somewhat hard” although this did not predict likelihood of reaching the target heart rate. Physical activity measured by pedometer steps predicted the likelihood of reaching the target heart rate for adults, but not for children. Changes in adiposity were not found for children or adults. Adults and children rated the program very high for enjoyment and acceptability. Thus, the Dance for Health program was found to demonstrate high levels of community engagement and enjoyment as a culturally appropriate, low cost program for increasing physical activity among children and their families. • A descriptive, cross-sectional quantitative study was conducted to determine how health literacy, race/ethnicity, income, and education influence parents’ underestimations of their child’s weight status (Howe, Alexander, & Stevenson, 2017). A convenience sample of parents (N = 160) of 213 children (7 to 13 years of age) was recruited from those who attended a free family night at a local children’s museum of science and history. A racially and ethnically diverse sample of parents (71.4% White, 16% African American, 5.2% Asian, 7.5% Other) with 32.5% Hispanic and 28.7% Non-White was recruited. The majority of parents (63.6%) were assessed to have adequate health literacy with approximately half (52.2%) of them being college educated and 44.1% with annual incomes over $70,000. Children (ages 7 to 13 years, mean 8.9 years) were classified according to
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weight status: healthy weight (53%), underweight (1.6%), overweight (25.4%) or obese (19.7%). The majority of parents underestimated their child’s weight regardless of actual weight status. Moreover, of the 45.1% of children who were classified as overweight or obese, only 7.5% of their parents correctly classified their weight status. However, no significant associations were found between parent characteristics of health literacy, race/ethnicity, income, and education with parent underestimations of their child’s weight status. A descriptive, cross-sectional quantitative study was employed to compare low-income mothers’ and fathers’ concerns about their young children’s (ages 3 to 10 years of age) weight status (Vollmer & Mobley, 2017). A convenience sample of low-income mothers (n = 30) and fathers (n = 30) was predominantly white (77% mothers; 67% fathers) and non-Hispanic (90% mothers; 93% fathers) and was recruited in a community setting. Eleven (36.7%) of the children were classified as overweight (BMI N 85th to b 95th percentile) or obese (BMI N95th percentile). Mothers’ perceived child weight and concerns about the child’s weight and future weight were not significantly associated with children’s BMI z-scores. However, there were significant associations between fathers’ perceived child weight and BMI z-scores, as well as concerns about the child’s future weight. Low-income fathers were more accurate and concerned than mothers with respect to their perceptions about the child’s weight status and the child’s future weight. Thus, healthcare providers need to provide education relative to children’s weight status for both low-income mothers and fathers. A secondary analysis of anthropometric data for students (N = 20,188) in K, 3rd, and 5th grades from 85 public elementary schools during the 2010–2011 school year in a predominantly Hispanic, large urban school district in the Southwest U.S. was conducted to determine the overweight and obesity rates among children, as well as the association with characteristics of the school, neighborhood, and geographic location (Santos, Huerta, Karki, & Cantarero, 2017). Generalized linear modeling (GLM) was used to analyze the data with respect to the social determinants of overweight and obesity rates by elementary school. The average proportion of overweight children (BMI N 85th percentile) by school was 30% (SD + 7%). Results indicate that the greater proportion (OR 2.4) of Hispanic students in a school was the one significant social determinant in determining the overweight and obesity rates of children in elementary schools. A descriptive qualitative study was conducted to understand parents’ experiences of stress, illness-related challenges, coping behaviors, and adaptation to the stress of caring for their young child with juvenile idiopathic arthritis (JIA) (Yuwen, Lewis, Walker, & Ward, 2017). Family Systems Theory integrated with the Resiliency Model of Family Stress, Adjustment, and Adaptation was used as the conceptual framework that guided the study. Nine parents (eight mothers; one father) from eight families participated in semi-structured, in-depth interviews about their experiences of providing care for their young child (age 2 to 5 years) with JIA. Interview data were analyzed using inductive content analysis and Atlas.ti qualitative analysis software. The core construct describing the parents’ experiences caring for their child with JIA was captured as Struggling in the Dark to Help my Child, as described by six domains: (a) Not knowing; (b) Reaching out in the dark; (c) Feeling my child’s pain; (d) Working out the kinks; (e) Feeling drained by the whole process; and (f) Being hard on the entire household. Thus, as parents struggled with the daily challenges of their child’s JIA, the multiple challenges of this chronic condition consumed their lives and had an impact on the physical and psychosocial health of the family. A review of the published literature from studies conducted in the U.S. or Canada that focused on the sociocultural factors that influence health outcomes for children with juvenile arthritis (JA) diagnosed prior to age 16 years was conducted using five electronic databases (PubMed, CINAHL, JSTOR, Web of Science, and PsycINFO) (Lewis,
Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013
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Brown, Tiziani, & Carrasco, 2017). The search yielded 46 articles that were reduced to a total of 16 articles that met the inclusion criteria. The five categories of social determinants of health, including biology, individual behaviors, social environment, physical environment, and health services, were used to organize the findings from this review. Child participants with JA across these studies were predominantly female and school-age children. Individual behaviors in the studies focused on physical activity/leisure, dietary modifications, psychosocial functioning, and vocational aspirations of children with JA. Social environment factors included race/ethnicity, psychosocial functioning, parental education level, child education level, and socioeconomic status/income. With respect to race/ethnicity of the samples across studies, 83.1% of the combined sample with JA was white, while three studies specifically focused on a minority samples. Physical environment was assessed in only two of the studies. Health services and insurance status were addressed in six studies. Taken together, the results of this review indicate that health disparities exist for children with JA of racial/ethnic minorities and low socioeconomic status. • An integrative review of the published literature was conducted using five electronic databases (CINAHL, Medline, PubMed, ScienceDirect, and PsycINFO) to determine barriers to addressing the psychological and social determinants of health in pediatric nursing practice with respect to children with chronic conditions or serious illnesses (Tallon, Kendall, Priddis, Newall, & Young, 2017). A total of 13 articles met the inclusion criteria and were evaluated for quality of evidence. Analysis of the literature indicated that healthcare providers identified specific barriers to addressing psychosocial issues among children with chronic conditions or serious illnesses and their families as the dominant use of the medical model of care with the primary focus on disease and treatment, rather than family-centered care. Although healthcare providers empathized with children and their families, they identified the lack of time, the perception that families prioritized physical care in contrast to psychosocial care, and the lack of confidence in healthcare providers’ communication skills to address psychosocial issues as barriers that prevented them from addressing the psychosocial and social issues influencing the health of children and their families. • An explanatory sequential mixed methods design was used to explore the impact of sleep problems on resilience in families of children with autism spectrum disorder (Roberts, Hunter, & Cheng, 2017). Mothers (N = 70) of children with autism spectrum disorder completed the quantitative survey about family resilience and children’s sleep habits. In-depth, qualitative interviews were conducted with six parents (five mothers and one father of five children) who reported that their child had sleep problems. Survey results indicated that parents of children with autism spectrum disorder with sleep problems reported significantly higher levels of family strains and family distress and significantly lower levels of resilience as compared to children who slept well. Regression analysis identified significant predictors of hardiness as greater social support, greater copingcoherence (stress management), and lower strain scores. Qualitative interviews revealed the parents’ views about how they have adapted to the child’s autism spectrum disorder and sleep problems, as captured by the overall theme, Journey toward Family Resilience, with six subthemes: (a) Finding the Trailhead; (b) Dual Pathways; (c) Crossing Paths and Choosing Travel Companions; (d) Forging New Paths; (e) Resting Along the Way; and (f) Seeing the Vistas. Thus, the integrated findings confirmed that families of children with autism spectrum disorder who had better sleep demonstrated more resilience as they adapted to their child’s chronic condition. • A descriptive qualitative study was used to explore the perspectives of mothers of infants with complex congenital heart disease with respect to coping with the stress of hospitalization in the cardiac intensive care unit (CICU), as well as to determine the acceptability and feasibility of mindfulness as a potential intervention for stress reduction (Golfenshtein, Deatrick, Lisanti, & Medoff-Cooper, 2017). Three focus
groups were conducted with mothers (N = 14) of infants with complex congenital heart disease hospitalized in the cardiac intensive care unit. Data analysis was conducted using content analysis and Atlas.ti qualitative analysis software. The majority (n = 13, 93%) of mothers were non-Hispanic white. Mothers described their experiences during the post-diagnostic period, surgery, and the CICU stay as extremely stressful. Mothers used both active and passive coping strategies, but their primary coping mechanism was emotion regulation, rather than problem-solving. Coping strategies were identified as: (a) seeking support systems, (b) positive thinking, (c) focus on the baby, (d) denial, and (e) distraction. Mindfulness as an active coping intervention strategy for stress reduction was introduced to the mothers at the end of the focus group sessions to determine acceptability and feasibility. These mothers expressed mixed reactions to the mindfulness intervention, although they found the mindfulness intervention to be acceptable and feasible for stress reduction. In addition, mothers identified potential barriers to implementation of the mindfulness intervention in the CICU. Thus, this study demonstrated that mothers of infants hospitalized in the CICU utilized emotion regulation as their primary coping strategy. • The usefulness of sociological conceptual frameworks is proposed for better understanding of sudden unexpected deaths in infancy among socially disadvantaged and vulnerable families (Shipstone, Young, & Kearney, 2017). It is important to note that the risk factors associated with socially disadvantaged families increase the risk for sudden unexpected deaths in infancy and reflect the broader social and economic conditions in which families live. Thus, it is critical to consider how these socioeconomic gradients influence sudden unexpected deaths in infancy and interact with biological and physiological factors, physical and social environment, as well as components of the healthcare delivery system. Thus, the authors recommend that researchers and healthcare providers utilize sociological frameworks and principles of behavioral economics to better understand socially disadvantaged and vulnerable families within a broader social and cultural context in order to reduce the risk for sudden unexpected deaths in infancy. • An integrative review was conducted to examine the published literature on chronic sorrow among parents of children with a chronic illness or disability from 1981 to 2015 (Coughin & Sethares, 2017). Of the 59 articles retrieved through a search of five online databases (CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and SocINDEX), 19 articles met the inclusion criteria to address the research questions. Articles were critically appraised for methodological rigor and a review matrix was developed. Eleven studies used a qualitative design, four employed a quantitative design, and four used a mixed methods approach. Findings across these studies indicated that the mothers experienced greater intensity of chronic sorrow about their child’s chronic illness or disability as compared to fathers. Moreover, mothers’ sorrow was permanent, while fathers were able to resolve their grief. Helpful strategies for parents to cope with chronic sorrow were identified and included the need for healthcare providers to demonstrate empathy and compassion for parents, and to provide information and explanations about their child’s condition, treatment and management, resources, and respite care. Parents reported unhelpful strategies by healthcare providers included poor communication, not listening to parents, conflicting information, inadequate time to learn care management, and lack of resources. Thus, chronic sorrow in parents is a consequence of chronic illness or disability in children. • A randomized controlled trial (RCT) was conducted in Turkey to determine the effectiveness of covering the eyes versus playing intrauterine sounds on premature infants’ pain and physiological parameters during venipuncture when compared to premature infants who did not receive the intervention (control) (Alemdar & Özdemir, 2017). Premature infants (N = 94) born at 28th to 36th gestational week were randomly assigned to one of three groups: covered eyes (n = 32), intrauterine sounds (n = 32), and control (n = 30). Statistically significant differences in level of pain after venipuncture were found
Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013
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for premature infants in the covered eyes and intrauterine sounds intervention groups (p b 0.05). However, no significant differences between groups were found for physiological parameters of heart rate or SO2 levels after venipuncture. Thus, covering the eyes and playing intrauterine sounds for premature infants were effective in reducing pain during venipuncture procedures. • A prospective randomized controlled trial (RCT) was conducted to compare the effectiveness of EMLA® with the J-Tip Needleless Injection System® in reducing children’s fear and pain associated with venipuncture for IV insertion (Stoltz & Manworren, 2017). Children (N = 150, ages 8 to 18 years) in the pre-operative suite were randomly assigned to EMLA® or J-Tip® intervention groups prior to IV insertion. Results indicated that children in the EMLA® group had significantly lower average self-reported pain scores as compared to those in the J-Tip® group (p b 0.001), and also had lower VAS pain scores. No significant differences in the levels of children’s fear were found between the EMLA® group and the J-Tip® group over time. Thus, the EMLA® intervention was found to be more effective in reducing the pain associated with venipuncture for IV insertion as compared to J-Tip® intervention. However, the authors noted that because there is a 60min wait time for EMLA to be effective, the clinical situation may require a more rapid treatment such as the J-Tip Needleless Injection System® to prevent IV insertion pain. • A cross-sectional survey was employed to describe nurses’ perceptions of the quality of care for children in Emergency Departments in Finland (Janjunen, Kankkunen, & Kvist, 2017). Nurses (N = 147) from four public Finnish hospitals with either pediatric emergency departments or general emergency departments that served adults and children were surveyed to evaluate the quality of care for pediatric patients. On average nurses had 7.7 years of emergency department experience, with a range of 0 to 15 years of experience in emergency care, and 64% worked in a general emergency department. Nurses rated the quality of professional practice in emergency departments to be high. Nurses in pediatric emergency departments had more positive evaluations of the quality of care for children higher than nurses from general emergency departments. Predictors of greater nursing satisfaction with the quality of pediatric care in emergency departments included higher levels of professional practice, more interdisciplinary collaboration, and adequate human resources. Thus, the quality of pediatric care in emergency departments as evaluated by nurses was related to the nurses’ professional practice.
As highlighted by these articles, it is essential for pediatric nurses to recognize the importance of the intersection between sociocultural and environmental contextual factors and the influence on health outcomes for children and their families. This interaction is especially significant for disadvantaged, vulnerable families and their children. To that end, intervention efforts need to address these interactions between sociocultural and environmental factors that influence health outcomes to improve the quality of care and health outcomes for children and their families. References Alemdar, D. K., & Özdemir, F. K. (2017). Effects of covering the eyes versus playing intrauterine sounds on premature infants’ pain and physiological parameters during venipuncture. Journal of Pediatric Nursing, 31 [XXX]. Bakula, D. M., Sharkey, C. M., Wolfe-Christensen, C., Mullins, A. J., Meyer, J., Mullins, L. L., & Wisniewski, A. B. (2017). Recommendations for the establishment of disorders/differences of sex development interdisciplinary care clinics for youth. Journal of Pediatric Nursing, 31 [XXX]. Bronfenbrenner, U. (2005). The bioecological theory of human development. In U. Bronfenbrenner (Ed.), Making human beings human: Bioecological perspectives on human development. Thousand Oaks, CA: Sage.
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Christian, B. J. (2011). Hallmark of excellence: Research and evidence-based practice as the foundation for quality pediatric nursing. Journal of Pediatric Nursing, 26, 170–171. Christian, B. J. (2013). Translational research — The imperative for integrating evidence into pediatric nursing practice to improve health outcomes. Journal of Pediatric Nursing, 28, 508–510. Christian, B. J. (2016). Translational research — New evidence for guiding intervention development to improve the lives of children and their families. Journal of Pediatric Nursing, 31, 214–216. Coughin, M. B., & Sethares, K. A. (2017). Chronic sorrow in parents of children with a chronic illness or disability: An integrative review. Journal of Pediatric Nursing, 31 [XXX]. Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health. Stockholm, Sweden: Institute for Future Studies [Available at: http://www. iffs.se/media/1326/20080109109110739filmZ8UVQv2wQFShMRF6cuT.pdf]. Golfenshtein, N., Deatrick, J. A., Lisanti, A. J., & Medoff-Cooper, B. (2017). Coping with the in the cardiac intensive care unit: Can mindfulness be the answer? Journal of Pediatric Nursing, 31 [XXX]. Hessels, A. J., Darby, S. W., Simpser, E., Saiman, L., & Larson, E. L. (2017). National testing of the Nursing-Kids Intensity of Care Survey for pediatric long-term care. Journal of Pediatric Nursing, 31 [XXX]. Hockenberry, M. J., & Wilson, D. (2015). Wong's nursing care of infants and children (10th Ed.). St. Louis: Mosby. Hong, E., & Kang, Y. (2017). Gender differences in sexual behaviors in Korean adolescents. Journal of Pediatric Nursing, 31 [XXX]. Horwitz, A. V. (2017). Social context, biology, and the definition of disorder. Journal of Health and Social Behavior, 58, 131–145. https://doi.org/10.1177/0022146517705165. Howe, C. J., Alexander, G., & Stevenson, J. (2017). Parents’ underestimations of child weight: Implications for obesity prevention. Journal of Pediatric Nursing, 31 [XXX]. Janjunen, K., Kankkunen, P., & Kvist, T. (2017). Nursing staffs’ perceptions of quality of care for children in emergency departments — High respect, low resources. Journal of Pediatric Nursing, 31 [XXX]. Kim, E., Boutain, D., Kim, S., Chun, J. -J., & Im, H. (2017). Integrating faith-based and community-based participatory research approaches to adapt the Korean parent training program. Journal of Pediatric Nursing, 31 [XXX]. Lewis, K. A., Brown, S. A., Tiziani, S., & Carrasco, R. (2017). Sociocultural considerations in juvenile arthritis: A review. Journal of Pediatric Nursing, 31 [XXX]. Lipsky, M. (2010). Street level bureaucracy — Dilemmas of the individual in public services. New York, NY: Russell Sage Foundation. McCormick, R. (2017). Does access to green space impact the mental well-being of children: A systematic review. Journal of Pediatric Nursing, 31 [XXX]. Melnyk, B. M., & Fineout-Overholt, E. (2014). Making the case for evidence-based practice and cultivating a spirit of inquiry. In B. M. Melnyk, & E. Fineout-Overholt (Eds.), Evidence-based practice in nursing and healthcare: A guide to best practice (pp. 3–24) (3rd Ed.). Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins. Morone, J. (2017). An integrative review of social determinants of health assessment and screening tools used in pediatrics. Journal of Pediatric Nursing, 31 [XXX]. Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th Ed.). Philadelphia: Lippincott Williams & Wilkins. Roberts, C. A., Hunter, J., & Cheng, A. -L. (2017). Resilience in families of children with autism and sleep problems. Journal of Pediatric Nursing, 31 [XXX]. Santos, R., Huerta, G., Karki, M., & Cantarero, A. (2017). Social determinants of overweight and obesity rates by elementary school in a predominantly Hispanic school district. Journal of Pediatric Nursing, 31 [XXX]. Schroeder, K., Ratcliffe, S. J., Perez, A., Earley, D., Bowman, C., & Lipman, T. H. (2017). Dance for health: An intergenerational program to increase access to physical activity. Journal of Pediatric Nursing, 31 [XXX]. Shipstone, R., Young, J., & Kearney, L. (2017). New frameworks for understanding sudden unexpected deaths in infancy (SUDI) in socially vulnerable families. Journal of Pediatric Nursing, 31 [XXX]. Stoltz, P., & Manworren, R. C. B. (2017). Comparison of children’s venipuncture fear and pain: Randomized controlled trial of EMLA® and J-Tip Needleless Injection System®. Journal of Pediatric Nursing, 31 [XXX]. Tallon, M. M., Kendall, G. E., Priddis, L., Newall, F., & Young, J. (2017). Barriers to addressing social determinants of health in pediatric nursing practice: An integrative review. Journal of Pediatric Nursing, 31 [XXX]. U.S. Department of Health and Human Services (HHS) (2017). Healthy People 2020, social determinants of health. Retrieved from: https://healthypeople.gov/2020/ topics-objectives/topic/social-determinants-of-health. Vessey, J. A., DiFazio, R. L., Strout, T. D., & Snyder, B. D. (2017). Impact of non-medical outof-pocket expenses on families of children with cerebral palsy following orthopaedic surgery. Journal of Pediatric Nursing, 31 [XXX]. Visekruna, S., Hall, L. M., Parry, M., & Spalding, K. (2017). Intersecting health policy and the social determinants of health in pediatric type 1 diabetes management and care. Journal of Pediatric Nursing, 31 [XXX]. Vollmer, R. L., & Mobley, A. R. (2017). Comparing low-income mothers’ and fathers’ concerns for young children’s weight status. Journal of Pediatric Nursing, 31 [XXX]. Yuwen, W., Lewis, F. M., Walker, A. J., & Ward, T. M. (2017). Struggling in the dark to help my child: Parents’ experience in caring for a young child with juvenile idiopathic arthritis. Journal of Pediatric Nursing, 31 [XXX]. Zhang, A., Padilla, Y. C., & Kim, Y. (2017). How early do social determinants of health begin to operate? Results from the Fragile Families and Child Well-being Study. Journal of Pediatric Nursing, 31 [XXX].
Please cite this article as: Christian, B.J., Translational Research — The Intersection Between Sociocultural and Environmental Factors and the Health of Children and Famili, Journal of Pediatric Nursing (2017), https://doi.org/10.1016/j.pedn.2017.09.013