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Upstream Interventions

accelerate upstream togetherWe’re continuing our deeper dive into HRSA/MCHB’s strategic paradigm “Accelerate Upstream Together”. This newsletter we’re exploring how the LCIRN is moving interventions “upstream” to either prevent the development of health challenges, or address and reverse them as soon as they occur. Upstream interventions are more likely to be successful than interventions that are applied only after conditions are well established.

Yet these interventions are also more challenging to design and implement because there are so many factors that contribute to the development of health challenges over long periods of time. The Life Course Health Development (LCHD) framework indicates that in order to develop effective upstream interventions we must understand those “pivot points” or key factors in a child’s developmental ecosystem that are most important in the genesis of health challenges, and how and when to intervene to act on them. Upstream interventions may address:

  1. Events and experiences early in life, including the sensitive pre-and peri-conception periods. Evidence suggests that certain aspects of this life stage are particularly important in setting the foundation for future health, including secure early relationships, capacity for emotional regulation and establishing healthy behaviors.
  2. Aspects of the child’s family and community environment that are not traditionally targeted by health interventions, including social and structural determinants of health – factors in the child’s family and community environments that can impact their sense of well-being and their life-long health.

In order to design and implement effective interventions to improve health, we need to understand when and how these factors exert their influence, and how to either prevent events or experiences that pose health threats from occurring, or to mitigate any potentially harmful effects once they occur.

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Intergenerational Migrant Health Interventions

Migrants experience significant changes in their social and cultural environments, some of which pose challenges to their health trajectories. The immigration experience is part of the history of America. In the past, as now, this experience occurred in a variety of contexts- for many it was a much welcomed, awaited and desired change with new hope for the future.  For others it was an unexpected response to a traumatic event, such as war or persecution, and for some the move was enforced and even at times against a person’s will. We are now starting to understand that the nature and consequences of the immigrant experience can have profound effects on a person’s health and well-being and can even impact the health of future generations.

The LCIRN is funding two pilot projects aimed at understanding and improving intergenerational migrant health:

  • Saltanat Childress, LCIRN Scholar and Assistant Professor of Social Work at the University of Texas-Arlington is studying ways to prevent Adverse Childhood Experiences (ACEs) and promote family well-being among immigrants from Central Asia and the former Soviet Union. Her pilot study “Family Wellbeing in Global Cultures: Establishing Foundations for Adaptive Interventions Across the Lifespan” aims to identify key socio-cultural and psychological risk and protective factors that can affect the family life of immigrants and refugees. She plans to explore how these factors are related to caregiver and child/adolescent outcomes, and what strategies are used to navigate family processes.
  • Kevin Roy, Professor of Social Work at the University of Maryland and Jerica Berge, Professor and Vice-Chair for Research, Dept Family Medicine and Community Health, University of Minnesota Medical School are conducting an LCIRN pilot study into the relationship between “Immigrant Father Involvement and Child Health/Well-Being over the Lifespan.” The role of immigrant fathers is an understudied aspect of life course health research. This mixed-methods study aims to explore how men and their families cope with the challenges of acculturation, economic setbacks, legal issues and constrained educational opportunities, and which factors promote or constrain their own and their family’s health and well-being.

By understanding more about these upstream factors and the way they impact life-long health and well-being, we can start to work alongside immigrant populations to co-create new types of interventions that will best address challenges and have a positive impact on health development trajectories.

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Intervention Spotlight: Family Foundations + Financial Coaching

We asked PI Mark Feinberg to give us an update on his new study which aims to combine the Family Foundations preventive co-parenting intervention with a financial coaching intervention.

Overview of the intervention:

We have begun a line of work that seeks to mitigate disparities between low-income and wealthier parents and children by providing education and skills-based coaching to expectant, low-income parents in financial management and co-managing household and child-related financial matters. We are developing a new prevention approach by adapting and integrating two evidence-based models: (1) a model of financial education and coaching for low-income individuals deployed by Capital Good Fund, a Rhode Island-based non-profit working in six states; and (2) a preventive intervention developed at PSU that helps first-time parents build supportive coparenting relationships (Family Foundations; FF).

Why was this adaptation needed? How will it help to accelerate progress?

There is great potential synergy in integrating the two areas: Finances are a major source of conflict among couples, particularly low-income couples who already have a high level of financial instability. Financial strain and interparental conflict contribute to key factors that undermine children’s development and well-being: parental stress and depression, father disengagement, and harsh parenting. This innovative project will not only integrate financial education and coaching with support for positive, cooperative coparenting, but also develop new material that supports low-income parents in extending coparenting skills (communication, problem-solving, joint family management) to cooperation and coordination around financial responsibilities. 

What makes this a life course intervention?

This approach is based in a life course health framework as financial strain and interparental conflict are linked risk factors for young children’s development, affecting basic physiological and psychological self-regulatory capacities with implications for health throughout the lifespan.conceptual model of family foundations co-parenting intervention shows connections between environment, parent relationships, and child well-being

What are the next steps?

To create the integrated program, we are first conducting qualitative interviews with racially/ethnically diverse, low-income parents to understand their experiences and concerns in the pregnancy and early childhood periods. We will then develop the adapted program, gain feedback on the new material from low-income parents, and finally conduct a pilot test to assess feasibility and generate data to support an NIH RO1 application for a randomized trial.

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Accelerating Upstream Together

accelerate upstream together

In our Year 3 in Review, we reflected on HRSA/MCHB’s strategic paradigm “Accelerate Upstream Together”. Let’s take a deeper dive into what we’re doing at the LCIRN around each of these topics, starting with “accelerate”.

Accelerate means to work faster to improve MCH outcomes and eliminate disparities. At the LCIRN we are approaching this in three ways.

  1. Making the switch from describing to intervening.

As researchers, we want to understand as much as possible about the processes that lead to healthy development and the ways that they can get off track. While observational epidemiological studies are invaluable, multiple studies that describe, essentially, the same associations are of limited use, and at a certain point we have to stop describing and start intervening. Process studies are still a part of our research portfolio – but only with a view to developing an intervention that can bring about an improvement in health status at individual and population levels. Making this switch is not easy.  Observational studies are quicker and frankly easier to perform. Planning, developing, designing, piloting and fielding a new intervention can take years, and can appear daunting to a new researcher whose research output is being closely monitored. Fortunately, we have senior investigators in the network who have experienced this path and are willing to provide mentorship to our scholars and junior researchers, as well as advocating for greater recognition of the work of intervention development in the faculty review process.

Join Us: Please consider advocating at your own institution for increased recognition of faculty effort in intervention development, especially interventions that are to be delivered in community settings and have a focus on health equity.

  1. Funding Pilot Studies

The LCIRN has made a commitment to devote a portion of our funding to supporting pilot studies that hold real promise for the development of new approaches to interventions. These pilot studies are being conducted by our LCIRN node members, who are mid-level or senior researchers testing an intervention in preparation for applying for funding for a larger study; and by our LCIRN Scholars, a group of early-career intervention researchers. Scholar Dr. Keisha Wint, for example, is piloting an intervention designed to help preschool teachers support children when they grieve. 

  1. Stacking and Bundling Effective Interventions

This approach takes interventions that already have a strong evidence base and links them together through an integrated delivery system to a targeted population such that the overall impact is greater than that of any one intervention alone. Drs. Michael Msall and Susan Hintz are developing the “Success After Prematurity” node around this concept – identifying and scaffolding existing interventions, then filling in the gaps, to ensure that low-income families of preemies have access to the resources and interventions they need to give their children the best opportunities for development.

Bundled interventions may be particularly effective when they address social determinants of health – e.g., Dr. Adam Schickedanz, leader of the LCIRN Adversity, Adaptation and Resilience Node has been studying the impact of medical-financial partnerships as a way to improve child and family health. Mark Feinberg, leader of the Family Health Development Node is studying new ways to couple his evidence-based co-parenting intervention, Family Foundations, with financial coaching.

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