Every day, individuals all over the world — some marginalized by ethnic identity or immigration status, others by geographic isolation or lack of material resources — fall through the cracks in healthcare systems. How do we make progress in these high-needs, low-access spaces, and what can we learn by bringing together experts from across the healthcare landscape? How do health practitioners serving seldom-engaged patients get the job done? How do researchers create the evidence needed to support that difficult work?
In the Reaching the Rarely Reached series, Mackenzie Whipps asked three NYU practitioner-researchers how and why they conduct research with populations that are often forgotten with in the healthcare system. Each expert targets a different social problem, and each uses novel strategies to better serve the communities they work with.
Our final expert is Dr. Alan Mendelsohn, a developmental pediatrician who has worked as a clinician at Bellevue Hospital Center in New York City and currently serves as an Associate Professor of Pediatrics and Population Health at NYU Langone. Dr. Mendelsohn’s work with low-income urban families in New York City has been recognized in both the academic, as well as non-academic communities; he has been featured in several public news outlets, most recently appearing in the New York Times. Along with his team at Bellevue, he developed the Video Interaction Project (VIP), which now serves many families in the city, most of whom are 1st or 2nd generation immigrants from Latin America.
VIP is a simple strategy with striking results. During each well-child pediatric visit between birth and a child’s 3rd birthday, parents meet with a specialist for about 20 minutes, right there in the clinic. During the visit, they play or read with their child while being videotaped; the specialist then shows the tape back to them, highlighting and validating the positive parenting moments that they see and guiding the parents to develop strategies in dealing with the more challenging moments. The result has been a decade worth of research showing positive, sustained impacts on parenting behaviors, school-readiness, and even healthcare utilization.
Dr. Mendelsohn is currently collaborating with Dr. Pamela Morris, as well as University of Pittsburgh’s Dr. Daniel Shaw, to carry out a large-scale, multi-site trial of VIP. The project, entitled “Smart Beginnings” is implementing a tiered approach to improve parenting and school readiness, testing the VIP in combination with a more targeted intervention called the Family Check-up. Smart Beginnings is funded by the National Institutes of Health and is still in data collection.
As a Pediatrician, what do you see as the largest barrier to engaging with low-income families?
There has always been a focus on prevention in Pediatrics – identifying disease early, delivering vaccines, etc. What has evolved over the past 50 years is a recognition that what constitutes health is more than just the absence of disease, but really relates to the broad context in which children grow and develop. I came in as an academic pediatrician, highly engaged in practice from the beginning, working with families facing numerous affronts to the social determinants of their health, the majority being low-income, immigrant-origin Latinx families. So, the idea that we could address disparities related to social determinants more broadly is something that a lot of us really took to heart as we went through our training and began to work with families who were at risk.
At the same time, there was this evolution away from the idea of a pediatrician working on their own, to a “medical home” model, where there are multiple disciplines collaborating to assess and address these issues. So, the idea to engage in this setting came to me, as it did for many others working in the community, from the recognition that one of the main places where all families get seen from birth to age three has been the pediatric well-child setting. Pediatrics was one of the places where we could engage in these areas at a population-wide, universal level.
What is important to remember is that engagement with hard-to-reach, or marginalized families, is more than just their attendance. And I think that engagement, in this setting, relates both to cultural sensitivity on the one hand, and using a strengths-based approach on the other. We need to engage families in common, shared goals — goals like wanting your kids to be healthy, to develop normally, to do well in school — even while recognizing that parents from different backgrounds do think about parenting and about their children in somewhat different ways. So, engagement for us is about building on those shared goals.
Technology can play a big role in new intervention strategies for improving parenting practices. Why did you decide to use video recording devices in your intervention?
At the time that we began the program, video recording was extraordinarily exotic, and families weren’t used to be video recorded. We weren’t sure, initially, whether families would find it okay – what we found was that a majority of families were interested in trying it out, and those who tried it out really liked it.
At the same time, in the infant mental health world, there was an idea developing that parent-child interactions were potentially a focus for treatment or prevention of insecure attachment or failure to thrive, for instance. And researchers in those fields were using video recording to work on these issues, and the idea to use this to promote positive parenting in a broad population was kind of a new idea.
There really is nothing more powerful than watching yourself on tape. I’ve had the opportunity to do it as part of my medical training, and I learned so much about where my strengths were and where I needed to build my skill set or change my approach. That concept really was one that drove me and others to utilize video recording and self-reflection with parents.
What state or national policies do you wish we could see in the next 10-20 years that would better serve low-income immigrant-origin families?
To my mind, the most important policy component is the identification of funding mechanisms for preventative interventions, whether in primary care or elsewhere. One of the biggest challenges has been the separation between health dollars and education dollars, and it’s been a real barrier to funding. What is really important is to find ways to fund primary prevention before problems arise — that should be a primary goal, and be funded as a primary goal, and I would like to see that happen.
Mackenzie Whipps is a 5th year doctoral student in the Psychology and Social Intervention program in the department of Applied Psychology.