Screening for Social Determinants of Health In Pediatric Settings
Screening for Social Determinants of Health In Pediatric Settings
Social determinants of health (SDoH) are the social and environmental factors that impact health and well-being. The Centers for Disease Control (CDC) outline the 5 domains of SDoH to be: economic stability, health care access & quality, education access & quality, neighborhoods & built environment, and social & community context. We know that multiple factors within each of these domains impact a significant proportion of health outcomes.
In last month’s “Know The Facts” article Social Connection: The Missing Piece in Addressing Social Determinants of Health, we talked about the social factors that influence health & well-being, and the ways that social prescribing can address this important, yet often overlooked, domain of SDoH.
Today, we’re diving deeper into the findings of 3 published studies looking at the implementation of and provider perspectives on SDoH screening tools within pediatric settings.
Before we dive in, let’s explore why it’s even important to screen for SDoH in clinical settings. These studies identified that many providers feel that the clinical setting is an opportune time to screen for SDoH as healthcare professionals have a unique relationship with patients. Specifically, within outpatient general pediatrics, infants and young children have frequent well child visits within their first 2 years of life, scheduled at developmentally appropriate ages where screening and intervention can yield positive impacts in the prevention of long-term conditions.
Another study reviewed factors related to screening of SDoH in pediatric intensive care unit (PICU) settings, stating that this is yet another opportunity to screen. Whereas, during outpatient pediatric visits, so much is needed to be covered within short visit times, including anticipatory guidance, vaccinations, and management of chronic conditions, the PICU offers a unique opportunity for screening. Additionally, the study noted that children with specific issues identified in their SDoH are at higher risk for more severe illness, comorbid conditions, and increased rehospitalization rates. If interventions can be implemented and resources provided to families through screening in the PICU, then perhaps this could play a vital role in preventing worsening of clinical disease and/or readmission rates.
Additionally, another study looking at provider perspectives on SDoH screening in clinical settings revealed that while many providers agree that screening within the clinical setting is ideal, particularly if resources are available to patients when issues are identified, they also find many barriers in screening to include:
Implementation.
Adding yet another screening tool to their already brief clinic visits and documentation process can be a challenge. Providers identified that they would find it preferable to have screening seamlessly integrated into the electronic medical health records, for example through a simple checkbox. They also expressed concerns that screening, and subsequent discussion on the screening results particularly if issues are identified, will also cut into the time they have to address their patient’s other medical conditions given their limited appointment time with each patient.
Patient Perspectives.
Many providers expressed concerns that patients may not understand why they are being asked these questions. This may be something they are not accustomed to. A high degree of provider-patient trust must be established for patients to feel comfortable disclosing much of this information. It must be explained to patients the reasons such questions are being asked. Providers also express concerns that patients may become overwhelmed, frustrated, or irritated by this line of questioning.
Provider Hesitations.
Many providers also listed their own discomfort with approaching social topics with their patients. They wonder how to approach such questions in a respectful, non-threatening manner while continuing to maintain their relational health with patients.
Within those pediatric clinical settings where screening is already taking place, data revealed a range of implementation strategies including collecting information via pen & paper, in-person interviews, phone interviews, computer, and tablet. Out of the various domains of SDoH screened in these settings, economic stability and neighborhood & built environment were most often screened for. Within those domains, the most common subcategories of screening were food insufficiency, housing instability, difficulty paying bills, meeting basic needs or making ends meet, interpersonal violence, mental illness or substance use among household members.
Interestingly, social and community context factors were the least screened domain. Yet, as was detailed in last month’s “Know The Facts” article Social Connection: The Missing Piece in Addressing Social Determinants of Health, we know that protective factors in terms of social cohesion and belonging impact health and well-being, and that the absence of these factors increase the risk of many conditions. We also know through an increasing body of research on social prescribing, that when patients are connected with social and community activities and resources, there is a resultant decrease in medical visits and improvement in various health outcomes Prescriptions To Promote Health: The New Wave Of Social Prescribing — Peace Out Portal
While it’s generally considered and recommended by many associations, including the American Academy of Pediatrics, to screen for social determinants of health in clinical settings, there are no standard assessment tools or known best practices for implementing such a screening process. Addressing these in the pediatric setting offers opportunities to intervene when prevention for long-term impacts is possible. Understanding the system-wide issues and barriers that currently exist to implementing such screening is an important first step to create solutions.
Further investigation is needed to determine: What would be an appropriate, standardized screening tool? What systems-issues need to be in place to facilitate the delivery of these screening tools in clinical settings (i.e. who will administer the screening? Who will review the results? What resources/referrals will be available?). This is, I believe, the starting point to implementing social prescribing initiatives - first the needs have to be known and addressed; the individuals who will benefit most from these services need to be identified so that the next steps (i.e. referral to resources) can be taken.
In conclusion, all these social determinants impact severity of illness, development of comorbid conditions, and readmission rates. Screening in clinical settings with appropriate resources and support referrals in place, can impact the long-term health and well-being outcomes for children and their families.
Resources:
Akande M, Paquette ET, Magee P, Perry-Eaddy MA, Fink EL, Slain KN. Screening for Social Determinants of Health in the Pediatric Intensive Care Unit: Recommendations for Clinicians. Crit Care Clin. 2023 Apr;39(2):341-355. doi: 10.1016/j.ccc.2022.09.009. Epub 2022 Nov 18. PMID: 36898778; PMCID: PMC10332174.
Sokol RL, Ammer J, Stein SF, Trout P, Mohammed L, Miller AL. Provider Perspectives on Screening for Social Determinants of Health in Pediatric Settings: A Qualitative Study. J Pediatr Health Care. 2021 Nov-Dec;35(6):577-586. doi: 10.1016/j.pedhc.2021.08.004. Epub 2021 Sep 11. PMID: 34521572; PMCID: PMC10860646.
Sokol R, Austin A, Chandler C, Byrum E, Bousquette J, Lancaster C, Doss G, Dotson A, Urbaeva V, Singichetti B, Brevard K, Wright ST, Lanier P, Shanahan M. Screening Children for Social Determinants of Health: A Systematic Review. Pediatrics. 2019 Oct;144(4):e20191622. doi: 10.1542/peds.2019-1622. Epub 2019 Sep 23. PMID: 31548335; PMCID: PMC6996928.