Section on Medical Students Resident and Fellowship Trainees (SOMSRFT)

1. Section on Medical Students Resident and Fellowship Trainees (SOMSRFT) Advocacy Campaign 2014-2015

2. SOMSRFT Annual Advocacy Campaign AAP Section on Medical Students, Residents and Fellowship Trainees (SOMSRFT) annual campaign focused on advocacy. Provides a framework for YOU to get involved, learn about advocacy, and implement an advocacy project of your own.

3. Past SOMSRFT Advocacy Campaigns 2013/2014: P.A.V.E. the Way to Firearm Injury Prevention 2012/2013: Read, Lead, Succeed 2011/2012: Vote for Kids 2010/2011: Childhood Obesity 2009/2010: ImmuneWise 2008/2009: Tobacco Cessation

4. Why Focus on Poverty? Poverty is a MEDICAL issue Poverty is a significant determinant of child health. Children living in poverty have poorer access to quality healthcare and worse health outcomes.Families living in poverty have higher infant mortality, greater risks for developmental delays, asthma, ear infections, obesity, poor nutrition, and child abuse and neglect. Child poverty adversely impacts health into adulthood. 2.AAP Agenda for Children Strategic Plan Poverty and Child Healthhttp://www.aap.org/en-us/about-the-aap/aap-facts/AAP-Agenda-for-Children-Strategic-Plan/Pages/AAP-Agenda-for-Children-Strategic-Plan-Poverty-Child-Health.aspx

6. What exactly is poverty? $23,850/year for a family of 4 • Does not vary based on geographic differences or cost of living. • Outdated: the manner in which “poverty”is calculated has not been updated since its inception in 1969. • Does not account for many of the expenses (nor the benefits) many families incur/receive. 3. US Department of Health and Human Services. Office for the Assistant Secretary for Planning and Evaluation. 2014 Poverty Guidelines. http://aspe.hhs.gov/poverty/14poverty.cf 4. Gabe T. Poverty in the United States: 2012. Congressional Research Service Report to Congress. November 13, 2013

7. Who Lives in Poverty? Nearly halfof ALL children live in poor/low‐income households. These families have difficultyaccessing health care and meetingthe basic needs crucial for healthy child development. In the U.S.in 2012: • 22% of children <18 lived in poverty • (16 million children) • 45% of children <18 lived in low‐income households • (32.7 million children) 2.AAP Agenda for Children Strategic Plan Poverty and Child Healthhttp://www.aap.org/en-us/about-the-aap/aap-facts/AAP-Agenda-for-Children-Strategic-Plan/Pages/AAP-Agenda-for-Children-Strategic-Plan-Poverty-Child-Health.aspx

8. Racial Disparities in Poverty Kids Count Data Center. Children In Poverty By Race And Ethnicity http://datacenter.kidscount.org/data/Line/44-children-in-poverty-by-race-and-ethnicity?loc=1&loct=1#1/any/false/868,133,35,17,15,13,11/asc/10,11,9,12,1,185/323

9. Suburban Poverty • Most pediatricians will care for low‐income/poor families. • Economic insecurity impacts a diverse child population, including children in suburban, urban, and rural communities. • Since 2008, suburbs have experienced the largest and fastest increase of poor populations. 2. AAP Agenda for Children Strategic Plan Poverty and Child Health http://www.aap.org/en-us/about-the-aap/aap-facts/AAP-Agenda-for-Children-Strategic-Plan/Pages/AAP-Agenda-for-Children-Strategic-Plan-Poverty-Child-Health.aspx#sthash.tdT6ZhOQ.dpuf

10. Poverty as a Medical Issue Poor educational outcomes: poor academic achievement, higher rates of HS dropout. More high risk behaviors: Early unprotected sex with increased teen pregnancy, Drug and alcohol abuse, Increased criminal behavior as adolescents and adults. Increased exposure to “toxic stress”: impacting memory, educational attainment, exaggerated response to stress, and more high risk behaviors. –Increased inflammatory markers leading to adult CV disease.

11. FACE Poverty F: Food security/nutrition A: Access C: Community E: Education

12. Food Security, Nutrition and Obesity • 14.6% of US households in 2008 were food insecure (unable to obtain adequate food). Among households with children it was 21%. • 45% of low income families are food insecure • What is “adequate food?” • Food insecurity can be assessed with the HFSS or the “Hunger Vital Signs.”

13. Food Security, Nutrition and Obesity • 31% greater odds of being hospitalized since birth. • 76% greater adjusted odds of being at increased developmental risk. • 90% greater adjusted odds of being in fair/poor health (versus good/excellent health).

14. Food Security, Nutrition and Obesity

15. How do you FACE food insecurity? Locally: • At the clinic: Check the Hunger Vital Signs • Encourage patients to sign up for WICand SNAP • Provide information about local food banks State: • Encourage summer lunch programs Nationally: • Lobby and promote the Healthy School Lunch bill • Advocate for continued SNAP funding and enhanced SNAP benefits for immigrant families

16. Access Increasing access to patient centered medical homes helps alleviate the effects of poverty on children. Medical home is an approach to providing primary care that is accessible, continuous, comprehensive, family‐centered, coordinated, compassionate and culturally effective. Outcomes: • Improved health • Improved well-being • More productive lives American Academy of Pediatrics. Medical Home Initiative for Children With Special Needs Project Advisory Committee, The Medical Home. Pediatrics Vol 110 No. 1 July 1 2002

17. Access - Medicaid and CHIP Medicaid and CHIP enrollment is open year-round! In most states these programs cover children in families with income up to 200% poverty level. American Academy of Pediatrics Committee on Child Health Financing. Children’s Health Insurance Program (CHIP): Accomplishments, Challenges, and Policy Recommendations. Pediatrics vol.133 no.3 March 2014

18. Access - Medicaid and CHIP Health Insurance Coverage of Children 0-18 We have made great strides in children’s health insurance coverage since 1990s. Since the introduction of CHIP, the rate of uninsured children in the US has declined significantly. American Academy of Pediatrics Committee on Child Health Financing. Children’s Health Insurance Program (CHIP): Accomplishments, Challenges, and Policy Recommendations. Pediatrics vol.133 no.3 March 2014

19. Access - Medicaid and CHIP The percentage and number of children covered by public health insurance (Medicaid and CHIP) has increased steadily since 1997. American Academy of Pediatrics Committee on Child Health Financing. Children’s Health Insurance Program (CHIP): Accomplishments, Challenges, and Policy Recommendations. Pediatrics vol.133 no.3 March 2014

20. How can we FACE Poverty by focusing on Access? @ the cliniclevel - provide information about CHIP and medicaid for parents. @ the community level - organize booth at back to school orientation and encourage parents to sign kids up for health insurance! @ thelegislativelevel - contact your representative as ask them to support policies that increase healthcare access. • Advocate for reauthorization of CHIP and encourage states to take CHIPRA option to allow legal immigrants CHIP without waiting 5 years -Write an op-ed or letter to the editor about how important access to healthcare and CHIP is to children.

21. Community & Cycle of Poverty

22. Cycle of Poverty = Persistence in Poverty Research: Between 1996-2006, most Americans in bottom 20% never moved up the income ladder. 20% of U.S. children <18 yrs live in poverty and likely to remain in poverty as adults. What fosters intergenerational cycles of poverty? Direct: living in poverty means lack of resources = inability to mobilize out of poverty. Indirect: Effects on child development result in harmed child resilience, poor cognitive development = helplessness, hopeless, little self-worth.

23. Proximal and Distal Influences in the Community: Contributions to poor EBCD = Cycle of Poverty

24. How can we FACE Poverty by focusing on the Community? Ecological Perspective of Poverty

25. Community: FACE Poverty Initiatives @ the Familylevel Advocate for increase paid parental leave Promote positive parenting methodwhen giving anticipatory guidance. Promote early literacy programs like Reach out and Read When communicating with families in clinic, use: Strength-based care Motivational Interviewing Shared decision making See resources below for other parenting strategies and clinic visit guidance that promote healthy child development.

26. Not only about going to school, also about effective schooling. Promote after school activities for your patients. Make a resources handout to give to families in clinic Promote Increased School Connectedness Team up with schools in the community to promote positive schooling. Eliminate ‘deficit perspectives,’ promote strength based teaching Community:FACE Poverty Initiatives @ the Schoollevel

27. Neighborhood interventions should come from those in the community. Collaborate with community to: Build safe places for play Improve neighborhood aesthetics Increase individual action to steer life path Community-driven development Access to places for physical activity, to supermarkets, to healthy food Community:FACE Poverty Initiatives @ the Neighborhoodlevel

28. #1 Early Childhood Education (Birth – Pre-formalschooling) The brain TRIPLES in size between birth and 2 years of age – this a CRITICAL time. Home visiting programs and quality child care are crucial Percent of 3-5 year olds enrolled in full-day prekindergarten increased from 21% in 1994 to 28% in 2012. 28%of America’s 4 yr olds enrolled in state-funded educational programin 2012-2013,unchanged from year prior. First time seen a decrease in # enrolled= actual number of children enrolled in 2012-2013 decreased (9,000 fewer 4 yr olds, 42 less 3 yr olds). Education

31. E

32. #2: High School Dropout: the Numbers and Prevention Strategies The Numbers: Over 1.2 million studentsdrop out of high school in the United States every year = 1 student every 26 seconds – or 7,000 a day. A high school dropout will earn $200,000 less than a high school graduate over his lifetime and almost a million dollars less than a college graduate. Almost 2,000 high schools across the U.S. graduate less than 60% of their students.

33. #2: High School Dropout: the Numbers and Prevention Strategies Prevention: @ the Clinic level: • Promote afterschool activities, free tutoring services, resources handout • Talk with teenagers about income gap (high school/college graduates vs dropouts) • Ask about future/life goals • Motivate, empower to reach for the stars @the Community • School and community collaborations • Professional development

34. Racial Disparities in Dropout Rates • There are higher rates of school dropouts among black and Hispanic youth as compared to white youth. • There is also a significantly higher drop out rate among youth that are foreign born and those whose parents are foreign born compared to children with native born parents

35. Clinic and Community • Compile a list of resources in your community that help lift families out of poverty to share with patients and other providers. • Distribute IHELLP badge cards to providers and educate others on obtaining social histories. • Wear your FACE Poverty badge holders and T-Shirts and help spread awareness.

36. Federal/State Advocacy • Read the Academy’s federal policy positions. • Contact your state and federal legislators -> Support policies that help lift families out of poverty. • All members of SOMSRFT are now automatically signed up to be a key contact and receive emails. • Organize or participate in a FACE poverty advocacy day at the state capitol. • Write an op-ed or letter to the editor.

37. Get Involved! • Organize a project at your school/program, in your community, state, or AAP district. • Read our FACE Poverty newsletters. • Give THIS lecture! • Join the SOMSRFT advocacy subcommittee. • Advocate through social media • Check out SOMSRFT social media toolkit #FACEPoverty • Visit our website: http://www2.aap.org/sections/ypn/r/advocacy/FACEPoverty.html

38. Acknowledgments Special Thanks to: Julie Raymond, CAE Barbara Miller Jamie Poslosky Steven Federico, MD, FAAP Benard Dreyer, MD, FAAP AAP Department Federal Affairs AAP Division of State Government Affairs AAP Poverty Workgroup SOMSRFT Advocacy Subcommittee: Danna Qunibi, MD Lauren Gambill, MD Jennifer Kusma Kym Gonzalez, MD Elizabeth Van Dyne, MD Jen Wolford, DO, FAAP Avika Dixit, MD Natasha Sriraman, MD, FAAP Philip Zachariah, MD Rebekah Kim, MD Michael Stratton John Carey, MD Courtney Smith, MD Catherine Urban, MD Irina Prelipcean, MD Nan Du Chirag Parikh Erin Kelly, MD Christian Pulcini, MD, MEd, MPH Kristin Schwarz, MD Puja Umaretiya Alison Mols Heather Abraham, MD Lisa Costello, MD Rathi Asaithambi, MD, MPH Sameer Vohra, MD Justin Schreiber, DO Kathleen Rooney, MD Shana Godfred-Cato, DO Angela Sandell, MD Anita Shah, DO Michael Epstein, MD Shae Anderson, MD Athra Kaviani, MD

39. Acknowledgments: AAP Poverty Workgroup • Andrew Racine, MD, PhD, FAAP (Chair) • Carole Allen, MD, FAAP • Steve Federico, MD, FAAP • Andrew Garner, MD, PhD, FAAP • Benjamin Gitterman, MD, FAAP • Renée Jenkins, MD, FAAP • Katie Plax, MD, FAAP • Barbara Ricks, MD, FAAP • Sarah Jane Schwarzenberg, MD, FAAP • Elizabeth Van Dyne, MD, FAAP • Benard Dreyer, MD, FAAP

40. Thank you!