Introduction
The International Society of Social Pediatrics and Child Health (ISSOP) defines social pediatrics as “a global, holistic and multidisciplinary approach to child health; it considers the health of the child within the context of their society…, integrating the physical, mental, and social dimensions of child health and development, as well as [health] care, prevention and promotion…” (Spencer et al.
2005).
Social pediatrics considers the needs of the whole child (Ford-Jones et al.
2008; Julien
2004). It has been described as a primary health care “linked in and linked across” with specialist health-care services, providing a spectrum of services beyond the traditional health-care system (Wong et al.
2012). Social pediatrics is an equity-oriented practice and philosophy that seeks to take action on the social determinants, such as income, housing, education and environment, as critical mediators of child and youth health.
Social pediatric initiatives (SPIs) target high-needs populations to facilitate proportionate distribution of health resources and provision of services to meet the needs of children and youth living in poverty who are often at higher risk for developmental delay or poor physical or mental health, who often miss out on routine screening, or do not benefit from diagnostic assessment, treatment and/or early intervention (Wong et al.
2012; Shonkoff et al.
2012; Power et al.
2007). While there are a number of equity-oriented clinical practices, those that are explicitly identified as SPIs operate primarily in ISSOP member countries in Europe, as well as Australia, USA and Canada. SPIs aim to improve health and developmental outcomes through increased reach, early intervention and increased service utilization (Ford-Jones et al.
2008). SPIs achieve their objectives through strategies including decentralized delivery of care in defined socio-geographic areas (i.e., place based) (Wong et al.
2012) close linkage with local communities, and cooperation and collaboration among multiple services and service providers (Kodner and Spreeuwenberg
2002) such as physicians, social workers, lawyers and other professionals to foster access to needed care (Julien
2004; Lynam et al.
2010).
Our interest, and the focus of this paper, was to take a realist approach to the examination of SPIs. To our knowledge, there are no systematic reviews of SPIs currently in the literature. Research documenting the need for SPIs spans a broad range, such as the mapping of child developmental vulnerabilities (Canada, Australia, UK), demonstrating the impact of toxic stress on children’s neural development (Brody et al.
2017; Hughes et al.
2017; Luby et al.
2017), and understanding conditions of children facing multiple forms of adversity (Werner
1992). However, there is limited outcome research, and while there have been a number of published studies that have applied the realist review method to complex social and health interventions, there are none that appear to reflect SPIs (Greenhalgh et al.
2007; Kane et al.
2010; Molnar et al.
2015; Pearson et al.
2015; McCormack et al.
2013).
Realist science seeks to generate explanations through observing patterns in the data that recur often enough to support hypothesized mechanisms of action (Pawson and Tilley
1977). These explanations are articulated as CMO (context-mechanism-outcome) configurations. Mechanisms theorize why an outcome was achieved (or not) based on participant reasoning or reaction (Jagosh et al.
2011). Mechanisms are not the intentional strategies or activities of program implementers. Astbury and Leeuw (
2010) characterize mechanisms as: (1) “…inferred from patterns in observed behaviour; (2) …sensitive to variations in context … [and] not always be deployed or ‘fired’; and (3) …once ‘fired’ will lead to a specific outcome.”
Realist synthesis involves iteratively building an explanatory framework examining the causal relationships behind an intervention (Jagosh et al.
2013), based on the available literature. The main principle underlying the realist approach is the development and testing of propositions that tie context, mechanism and outcome (CMO) together (Pawson and Tilley
1977). The aim of this realist synthesis is to better understand how SPIs work, for whom and under what circumstances, in order to produce an explanatory model to assist decision makers in developing and planning equitable, integrated, embedded approaches to child and family health.
Discussion
This realist synthesis aimed to identify processes of care (through CMOs) that may improve health and developmental outcomes for children and youth coping with adverse social and material circumstances. Our analysis identified four consistent patterns tying together contexts (shared values, vulnerable families, institutional support), mechanism (sharing power, self-reliance, bridging trust, practitioner confidence) and measured outcomes, such as successful provider partnerships, increased client reach, and increased referral to health and community services to provide explanatory insight into how SPIs may achieve their goals. The study is unique because it has focused on the process of “how” outcomes are achieved (i.e., mechanisms), thereby offering direction for the knowledge, skills, and philosophical orientation clinicians need to effectively develop relationships and form partnerships in SPIs.
Lynam et al. (
2011) identify that a central, yet often unexamined, assumption of primary health care is that families have the knowledge, skills and resources to navigate the health-care system, follow through on referrals, enact recommended treatment, and clearly present their concerns about their child to health-care providers in order to initiate treatment. However, in the context of vulnerabilities that arise out of social, material and historical circumstances, many parents are not “confident advocates” for their children, or parents may recognize a need for support for their child but their ability to act on the need is constrained by a number of factors, including a lack of knowledge of child development, health systems organization, or of their rights. In addition, there were indications in our data that practitioner comfort and confidence needs to extend into the area of providing care to vulnerable populations in general. Practitioner knowledge of the social, material and organizational conditions that contribute to inequities appears to be critical to the delivery of appropriate referrals for social and medical conditions. Wong et al. (
2012) argue that empowering patients through knowledge allows families on the margins to become more active participants in their care and that perceived empowerment was related to clinician behavior. We found both empowerment processes were linked to increased use of services.
Trust and empowerment are shown to be fundamental cornerstones of successful SPIs. Both were present in different ways for practitioners and patients. Practitioners needed to trust each other, and they needed to be empowered by their organizations to pursue this “different kind of care,” a phrase coined by Julien (
2004). Patients needed to overcome barriers to trust their practitioners in order to be empowered by the SPI for treatment of social and medical circumstances. Notably, we found that the context and history of the target population likely had a significant effect on the way the programs worked to build trust which influenced their successful delivery.
Lastly, our understanding of SPIs is that they are built upon a structure of horizontal partnerships in which knowledge and power is shared by practitioners, partners and families. Our conceptualization of horizontal partnerships encompasses the principle of symbiosis noted in horizontal collaboration (Inside Supply Management
2012) and the concept of limiting hierarchy noted in horizontal business organization (Quain
2018). It also includes horizontal communication, which legitimizes and validates community-based knowledge, derived from lived experience and local conditions (Bradford
2005). This is in keeping with analyses of primary health-care quality indicators and feminist theorizing about conditions that foster the broadest forms of engagement across individuals and organizations with differential power, in part because it recognizes and values different forms of expertise. In addition to the critical point of sharing power with other service partners, authors currently practicing with SPIs describe working environments embodying horizontal partnership where clients are considered an equal partner, where power is shared across patients and providers, where leadership is devolved, and group decisions and actions are driven almost exclusively by the shared vision of improving outcomes for vulnerable children and families.
A strength of this research was the close involvement of practice-based knowledge users. Limitations stem from a lack of clear definition of the social pediatrics term and a paucity of current literature exploring social pediatrics as a defined practice model. For this realist review, we focused on clinical programs that operationalizing all 3 dimensions of the social pediatrics philosophy (equity, integration and embeddedness). We excluded broad social policies that also met these criteria but did not have comparable outcomes for the purposes of this realist review. In addition, issues of attribution would arise in looking at these policy evaluations (for which there was also limited literature available). While we did find published descriptions of SPIs, there were limited evaluations reporting measured qualitative or quantitative outcomes available for comparison. As a result of the available literature, our results were highly influenced by one SPI in particular, the Responsive Interdisciplinary Child-Community Health Education and Research (RICHER) [4], which had the largest number of related articles that also provided the thickest descriptions of context and mechanisms.
This paper contributes to a limited evidence base on delivery of the SPI philosophy of care. The next steps in the research process are to identify the attributes of practitioners and clinicians who engage in inter-sectoral work. We would also like to discern the organizational features, such as policies and resources, which are needed to successfully introduce the suggested model of practice. Finally, future research needs to be done to identify the range and nature of the outcomes that can be achieved through an integrated, embedded, and healthy equity focused social pediatrics approach. By identifying the organizational structures that underpin integrated outreach partnership models of care, this research insights offer guidance for organizational leaders whose institutions/programs have a mandate to address child/youth health inequities and may be applicable to other health services initiatives aiming to reduce inequities.
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