Screening for Social Determinants of Health Among Children and Families Living in Poverty: A Guide for Clinicians

Health literacy & Chagas disease knowledge: A cross-sectional study in Southern Loja Province, Ecuador

Objective

Health literacy is associated with many patient outcomes. This study sought to determine the association between a person's level of health literacy and their knowledge about Chagas disease.

Methods

A cross-sectional survey was conducted with people living in two counties in rural Loja Province, Ecuador who attended a mobile health clinic. The communities in which the study was conducted are at high risk of Chagas disease and have limited access to both health care and educational resources. The Spanish version of Short Assessment for Health Literacy measured health literacy. The Chagas Disease Knowledge questionnaire measured knowledge of Chagas disease. T-tests and correlational analysis were used to assess associations.

Results

Overall 85 people participated in this study. A majority of the respondents were female (64.1%), and a plurality were married (40.7%) and had education less than secondary (40.7%). The average age of the sample was 44.31 ± 18.85. Health literacy levels and Chagas disease knowledge in the communities were low. About half of people had inadequate health literacy. No association between health literacy and Chagas knowledge was found.

Conclusion

Health literacy levels and Chagas disease knowledge were not found to be correlated. Explanations for the lack of association may include common causes of inadequate investment in Chagas disease education as well as neglect of health systems in rural Ecuador. Efforts to improve both health literacy and Chagas disease knowledge in poorer, rural areas of Ecuador are needed.

Innovation

This is the first study to assess relationships between health literacy and knowledge of Chagas disease in an uninfected population. For novel conditions, relationships between health literacy and disease knowledge should be investigated before communication campaigns are adapted.

Associations of adverse childhood experiences with blood pressure among early adolescents in the United States

The associations of adverse childhood experiences (ACEs) with blood pressure in adulthood are inconclusive. Similarly, the association between ACEs and blood pressure earlier in the life course is understudied. This study aims to assess the associations of ACEs with blood pressure among early adolescents. We utilized data collected at baseline (age: 9-10 years) and Year 2 follow-up from 4077 participants in the Adolescent Brain Cognitive Development (ABCD) Study. We used adjusted multiple linear regression models to estimate the associations of ACEs (cumulative score and subtypes) at baseline with systolic blood pressure (SBP) and diastolic blood pressure (DBP) at year 2 of follow-up. Experiencing ≥4 ACEs (compared to 0) was significantly associated with higher SBP (B = 3.31, 95 % CI 0.03, 6.57, p = 0.048). Of the ACEs subtypes, household substance use (B = 2.28, 95 % CI 0.28, 4.28, p = 0.028) and divorce or separation (B = 2.08, 95 % CI 0.01, 4.15, p = 0.048) were both significantly associated with a higher SBP while household mental illness (B = 2.57, 95 % CI 1.32, 3.81, p < 0.001) was significantly associated with a higher DBP. Our findings suggest that exposure to multiple ACEs is associated with higher blood pressure in adolescence.

Prenatal and Pediatric Primary Care-Based Child Obesity Prevention: Effects of Adverse Social Determinants of Health on Intervention Attendance and Impact

Background: Adverse social determinants of health (SDoHs), specifically psychosocial stressors and material hardships, are associated with early childhood obesity. Less is known about whether adverse SDoHs modify the efficacy of early childhood obesity prevention programs. Methods: We conducted a secondary analysis of publicly insured birthing parent-child dyads with Latino backgrounds participating in a randomized controlled trial of the Starting Early Program (StEP), a child obesity prevention program beginning in pregnancy. We measured baseline adverse SDoHs categorized as psychosocial stressors (low social support, single marital status, and maternal depressive symptoms) and material hardships (food insecurity, housing disrepair, and financial difficulties) individually and cumulatively in the third trimester. Logistic regression models tested effects of adverse SDoHs on StEP attendance. We then tested whether adverse SDoHs moderated intervention impacts on weight at age 2 years. Results: We observed heterogeneous effects of adverse SDoHs on outcomes in 358 parent-child dyads. While housing disrepair decreased odds of higher attendance [adjusted odds ratio (aOR) 0.52, 95% confidence interval (CI): 0.29-0.94], high levels of psychosocial stressors doubled odds of higher attendance (aOR 2.36, 95% CI: 1.04-5.34). Similarly, while certain adverse SDoHs diminished StEP impact on weight (e.g., housing disrepair), others (e.g., high psychosocial stress) enhanced StEP impact on weight. Conclusions: Effects of adverse SDoHs on intervention outcomes depend on the specific adverse SDoH. Highest engagement and benefit occurred in those with high psychosocial stress at baseline, suggesting that StEP components may mitigate aspects of psychosocial stressors. Findings also support integration of adverse SDoH assessment into strategies to enhance obesity prevention impacts on families with material hardships. Trial Registration: This study is registered on clinicaltrials.gov: Starting Early Obesity Prevention Program (NCT01541761); https://clinicaltrials.gov/ct2/show/NCT01541761.

Assessment of Adverse Childhood Experiences and Social Determinants of Health: A Survey of Practices in Pediatric Weight Management Programs

Introduction: Adverse childhood experiences (ACEs) and social determinants of health (SDoH) are associated with increased incidence of pediatric obesity. Recent literature highlights an imperative need to assess ACEs and SDoH among youth and families with obesity to identify those individuals requiring targeted interventions. The primary objective of the present study was to examine the frequency, methodology, and barriers in evaluation of ACEs and SDoH within pediatric weight management programs (PWMPs). Methods: Invitations were e-mailed to a comprehensive directory of 92 PWMPs in the United States with a link to complete an electronic survey. Results: Forty-one PWMPs from 26 states completed the survey. Assessment of one or more ACEs and SDoH was common and typically took place during the initial patient visit by the psychologist or medical practitioner through unstructured conversations. Reported barriers to assessment included lack of time to assess and to follow-up, lack of clinic protocols, and inadequate referral resources. Programs offering bariatric surgery and those with embedded mental health clinicians reported fewer barriers to ACEs/SDoH referral resources, while family-based and healthy lifestyle-focused programs perceived more barriers related to insufficient support staff and time to follow-up with families. Conclusions: Most PWMPs assess a subset of ACEs and SDoH; however, approaches to assessment vary, are often unstructured, and several barriers remain to optimizing assessment and follow-up. Future research should evaluate standardized ACEs/SDoH assessment protocols, ideal workflow, and their impact on obesity treatment and related health outcomes.

Social Care Education and Training Among US Pediatric Emergency Medicine Fellowship Programs

OBJECTIVE

The aim of the study is to assess the association of social determinants of health (SDOH) education and social needs training on pediatric emergency medicine (PEM) physician perception and practices of social care.

METHODS

Data were derived from the 2021 National Social Care Practices Survey of PEM program directors (PDs) and fellows. Ordinal and binary logistic regression modeling were completed for educational/training factors and social care perspective and practice outcomes.

RESULTS

A national sample of 44 PDs (49% response rate) and 109 fellows (28%) participated. A minority of fellows received SDOH education and social needs training during fellowship. Fellows and PDs with SDOH education had a 3.1 odds (95% confidence interval CI, 1.4-6.9) of screening for social needs, with 4.4 odds among fellows (95% CI, 1.2-20.7). Those with social needs training were more comfortable assessing social risk, with 2.4 odds overall (95% CI, 1.2-4.7) and 3.1 odds among fellows (95% CI, 1.4-6.7). They also had 2.4 odds overall (95% CI, 1.1-4.9) of screening for social needs, with a 2.9 odds among fellows (95% CI, 1.3-6.8).

CONCLUSIONS

Social care education and training appear to be associated with comfort assessing social risk and social needs screening tendency among both PEM PDs and fellows. Key areas for educational interventions are identified among PEM fellows, who are uniquely positioned as clinical leaders and patient advocates.

Social Determinants of Health and Perceived Cognitive Difficulties in High School Students in the United States

OBJECTIVE

The United States Centers for Disease Control and Prevention (CDC) conducted the Adolescent Behavior and Experiences Survey (ABES) to examine disruption and adversity during the COVID-19 pandemic. We examined the association between social determinants of health (SDoH) and cognitive problems attributed to physical or mental health problems among high school students.

METHOD

The ABES was an online survey. Perceived cognitive problems were assessed with the question: "Because of a physical, mental, or emotional problem, do you have serious difficulty concentrating, remembering, or making decisions?" A SDoH index was created by summing endorsements to 12 variables.

RESULTS

Participants were 6,992 students, age 14-18, with 3,294 boys (47%) and 3,698 girls (53%). Many adolescents reported experiencing cognitive problems (i.e., 45%), with girls (56%) more likely to report cognitive difficulties than boys (33%) [χ2(1) = 392.55, p < 0.001]. Having poor mental health was strongly associated with cognitive problems in both girls [81%, χ2(1, 3680) = 650.20, p < 0.001] and boys [67%, χ2(1, 3267) = 418.69, p < 0.001]. There was a positive, linear association between the number of SDoH experienced and reporting cognitive problems. Binary logistic regressions were used to identify predictors of cognitive difficulty for both boys and girls (e.g., being bullied electronically, experiencing food insecurity during the pandemic, being treated unfairly because of their race or ethnicity, and being in a physical fight).

CONCLUSIONS

A strikingly high proportion of adolescents reported experiencing problems with their cognitive functioning. After adjusting for current mental health problems, several SDoH remained associated with adolescents' reported cognitive difficulties, including experiencing racism, bullying, parental job loss, and food insecurity.

Factors associated with having uncontrolled asthma in rural Appalachia

BACKGROUND

Chronic respiratory disease disproportionately affects residents of Appalachia, particularly those residing in Central Appalachia. Asthma is particularly burdensome to Central Appalachian residents regarding cost and disability. Improving our understanding of how to mitigate these burdens requires understanding the factors influencing asthma control among individuals with asthma living in Central Appalachia, specifically rural Kentucky.

METHODS

This community-based, cross-sectional epidemiologic study used survey data to identify characteristics associated with uncontrolled and controlled asthma. The designation of "uncontrolled asthma" was based on a self-report of ≥ 2 asthma exacerbations in the past year. Individuals with ≤ 1 or no exacerbations were considered to have controlled asthma. Chi-square or Fisher exact tests assessed the association between categorical variables and asthma control categories. Logistic regression was conducted to determine the impact of factors on the likelihood of uncontrolled asthma.

RESULTS

In a sample of 211 individuals with self-reported asthma, 29% (n = 61, 46 females) had uncontrolled asthma. Predictors of uncontrolled asthma included depression (odds ratio 2.61, 95% CI 1.22-5.61, p = .014) and living in multi-unit housing (odds ratio 4.99, 95% CI 1.47-16.96, p = .010) when controlling for age, sex, financial status, and occupation. Being overweight or obese was not a predictor of uncontrolled asthma. Physical activity and BMI did not predict the likelihood of uncontrolled asthma.

CONCLUSION

This study highlights significant challenges rural communities in Appalachian Kentucky face in managing asthma. Factors like depression, housing conditions, and a lack of self-management strategies play pivotal roles in asthma control in this population.

Barriers to and opportunities for advancing racial equity in cervical cancer screening in the United States

BACKGROUND

In the United States (U.S.), racially minoritized people have higher rates of cervical cancer morbidity and mortality compared to white individuals as a result of racialized structural, social, economic, and health care inequities. However, cervical cancer screening guidelines are based on studies of predominately white individuals and do not substantially discuss or address racialized cervical cancer inequities and their social determinants, including racism.

METHODS

We conducted in-depth interviews with health care providers (N = 30) and key informants with expertise in health equity (N = 18). We utilized semi-structured interview guides that addressed providers' views and experiences delivering cervical cancer screening to racially minoritized individuals and key informants' recommendations for advancing racial equity in the development and implementation of cervical cancer screening guidelines. Interviews were analyzed using a template style thematic analysis approach involving deductive and inductive coding, memo writing, and matrix analysis for theme development.

RESULTS

Most health care providers adopted a universal, one-size-fits-all approach to cervical cancer screening with the stated goal of ensuring racial equality. Despite frequently acknowledging the existence of racialized cervical cancer inequities, few providers recognized the role of social inequities in influencing them, and none discussed the impact of racism. In contrast, key informants overwhelmingly recommended that providers adopt an approach to cervical cancer screening and follow-up care that recognizes the role of racism in shaping racialized cervical cancer and related social inequities, is developed in partnership with racially minoritized communities, and involves person-centered, structurally-competent, and trauma-informed practices that address racially minoritized peoples' unique lived experiences in historical and social context. This racism-conscious approach is not to be confused with race-based medicine, which is an essentialist and racist approach to health care that treats race as a biological variable rather than as a social and political construct.

CONCLUSIONS

Developers and implementers of cervical cancer screening guidelines should explicitly recognize and address the impact of racism on cervical cancer screening, follow-up care, and outcomes, meaningfully incorporate racially minoritized communities' perspectives and experiences, and facilitate provider- and institutional-level practices that foster racial equity in cervical cancer.

Screening for adverse social conditions in child healthcare settings: protocol for a systematic review

INTRODUCTION

Adverse social conditions affect children's development and health outcomes from preconception throughout their life course. Early identification of adverse conditions is essential for early support of children and their families. Healthcare contacts with children provide a unique opportunity to screen for adverse social conditions and to take preventive action to identify and address emerging, potentially harmful or accumulating social problems. The aim of our study is to identify and describe available screening tools in outpatient and inpatient healthcare settings that capture social conditions that may affect children's development, health or well-being.

METHODS AND ANALYSIS

We will conduct a systematic review and will report the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. A systematic search of three databases (PubMed (Ovid), PsycInfo (EBSCOhost) and Web of Science Core Collection (Clarivate)) for English-language and German-language articles from 2014 to date will be conducted. We will include peer-reviewed articles that develop, describe, test or use an instrument to screen children for multiple social conditions in paediatric clinics or other outpatient or inpatient child healthcare settings. Key study characteristics and information on screening tools will be extracted and presented in structured tables to summarise the available evidence. We will assess the methodological quality of the instruments with the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study as we will not be collecting any personal data. Dissemination will consist of publications, presentations, and other knowledge translation activities.

Assessing and addressing social determinants of health in school-based health centers in King County, Washington

Objective

School-Based Health Centers (SBHCs) can reduce barriers to accessing care for school-aged children and adolescents. However, current practices related to screening for and responding to social determinants of health (SDOH) in SBHCs are unknown. Our study sought to understand SBHC staff's knowledge related to SDOH, and their screening and referral practices for addressing SDOH.

Methods

This study was conducted with all SBHCs in King County, Washington (n = 30 clinics operated by n = 8 agencies) between January-March 2022. Data were collected using a web-based questionnaire, distributed to all provider and clinical care staff (n = 222) in these SHBCs.

Results

While respondents had strong generalized knowledge regarding SDOH and how they impact health, they were less confident about the specific SDOH impacting the students they serve. Many health limiting and promoting factors are screened for by respondents; however, there was no standardization related to screening and referral practices across SBHCs or agencies. Respondents had suggestions on how to improve screening methodology and ensure that existing practices adequately assess the SDOH impacting student's lives. There was no clearly identified mechanism for making and following up on referrals. Respondents felt that there were either not or only sometimes enough resources available to meet student's needs.

Conclusion

SBHCs advance health and educational outcomes for students, yet SDOH are inconsistently assessed and addressed within SBHCs in King County. Standardizing processes for SDOH assessment and referral can help SBHCs develop practices that are in the best service of equity for their student populations.

The influence of social and environmental determinants of health on hospitalizations for pediatric asthma

BACKGROUND

Asthma is the most common chronic disease of childhood, and has several social, environmental, and demographic factors potentially influential to its disease burden. This study sought to determine the influence of these factors on hospital admissions and readmissions for pediatric asthma.

METHODS

This was a retrospective cohort study using data from the Indiana Network for Patient Care, a state-wide health information exchange in the United States. Study participants were children 2-18 years old admitted to the hospital with a respiratory diagnostic code between 2010 and 2021. Clinical variables were obtained from electronic health record data, and social and environmental determinants of health data were obtained from the Indiana Social Assets and Vulnerabilities Indicators using geocoding systems. Negative binomial models were used to examine community level social and environmental risk factors modifying the relationship between patient characteristics and the risk of asthma-related hospitalizations and 30-day readmissions.

RESULTS

The study sample included 25,063 patients with an average follow-up of 9 (SD = 5) years. Of these, there were 17,816 asthma-related admissions. There were a total of 1,037 asthma-related 30-day readmissions, with an incidence rate of readmissions relative to total visits of 0.028 per person-year. A high social vulnerability index (SVI) was associated with an increased rate of hospital admissions (Proportion attributable ratio: 1.09, 95%CI (1.03,1.15), p < 0.05). No environmental determinants of health were significantly associated with hospitalization rate.

CONCLUSION

High SVI was significantly associated with increased risk of total hospital admissions for pediatric asthma.

Association of Neighborhood Opportunity With Severity of Retinoblastoma at Presentation

PURPOSE

To examine the relationship between the Child Opportunity Index (COI) and severity of retinoblastoma at presentation.

DESIGN

Cross-sectional study.

METHODS

Children (age <18 years) treated for retinoblastoma at a tertiary care center between January 2000 and May 2023 were included. Residential census tract was used to determine the overall and domain-specific COI score for each child. Collected variables included age, sex, race/ethnicity, insurance type, and the International Classification of Retinoblastoma (ICRB) Group at initial examination. The primary outcome was Group D or E retinoblastoma at presentation. Mixed effects regression models were used to estimate the association of COI scores with disease severity at presentation.

RESULTS

This study included 125 children (51.2% male). Median age at diagnosis was 13 months (IQR, 5-24 months). One hundred nine (87.2%) children presented with Group D or E retinoblastoma and 33 (26.4%) resided in low or very low opportunity neighborhoods. Children residing in neighborhoods with low overall COI scores (OR, 1.62; 95% CI, 1.01-2.58; P = .044) and low education COI scores (OR, 1.77; 95% CI, 1.13-2.79; P = .013) were at increased odds of presenting with ICRB Group D or E retinoblastoma after adjusting for individual-level socioeconomic factors.

CONCLUSION

Children residing in low opportunity neighborhoods-particularly low education opportunity-more often presented with advanced stage retinoblastoma than children residing in neighborhoods with higher opportunity scores. Efforts to improve preventative vision care and access to eye specialty care for children residing in low-resource areas are needed to reduce existing disparities in retinoblastoma.

Addressing adverse social determinants of health in pediatric primary care: Study protocol for a hybrid type 2 effectiveness-implementation randomized controlled trial in two national pediatric practice-based research networks

BACKGROUND

Growing evidence linking social determinants of health (SDOH) to child health outcomes has prompted widespread recommendations for pediatricians to screen and refer for adverse SDOH at primary care visits. Yet there is little evidence to date demonstrating the effectiveness of practice-based SDOH screening and referral interventions on increasing family engagement with resources. This hybrid type 2 effectiveness-implementation trial aims to demonstrate the non-inferiority of a low-touch implementation strategy in order to facilitate dissemination of an existing SDOH screening and referral system (WE CARE) and demonstrate its effectiveness and sustainability in various pediatric practices.

METHODS

We recruited eighteen pediatric practices in fourteen US states through two pediatric practice-based research networks. For this stepped wedge cluster RCT, practices serve as their own controls during the Usual Care phase and implement WE CARE during the intervention phase via one of two randomized implementation strategies: self-directed, pre-recorded webinar vs. study team-facilitated, live webinar. We collect data at practice, clinician/staff, and parent levels to assess outcomes grounded in the Proctor Conceptual Model of Implementation Research. We use generalized mixed effects models and differences in proportions to compare rates of resource referrals by implementation strategy, and intention-to-treat analysis to compare odds of engagement with new resources among families enrolled in the Usual Care vs. WE CARE phases.

DISCUSSION

Findings from this trial may inform decisions about broader dissemination of SDOH screening systems into a diverse spectrum of pediatric practices across the US and potentially minimize the impact of adverse SDOH on children and families.

Early Childcare Precarity and Subsequent Maternal Health

PURPOSE

We examined prospective associations between early childcare precarity, or the security and reliability of childcare arrangements, and subsequent maternal health.

STUDY DESIGN

We conducted a secondary analysis of survey responses from mothers of 2,836 children in the Future of Families and Child Wellbeing study. We assessed the following childcare measures: insecure childcare, insecure childcare with missed work, inadequate childcare, and emergency childcare support. We used linear and logistic regression models with robust standard errors to examine associations between these measures when the index child was age 3 and maternal health outcomes (overall health, depression, and parenting stress) later when the child was age 9. We then examined additive experiences of childcare measures across child ages 1 and 3 on maternal health outcomes.

RESULTS

Early inadequate childcare was associated with higher odds of later poor maternal overall health (adjusted odds ratio [aOR], 1.64; 95% confidence interval [CI], 1.11-2.41). All early childcare precarity measures were associated with higher odds of maternal depression (insecure childcare [aOR, 1.64; 95% CI, 1.23-2.18]; insecure childcare with missed work [aOR, 1.58; 95% CI, 1.13-2.22]; and inadequate childcare [aOR, 1.75; 95% CI, 1.22-2.51]). Emergency childcare support was associated with lower odds of adverse maternal health outcomes (poor overall health [aOR, 0.65; 95% CI, 0.48 to 0.88]; depression [aOR, 0.73; 95% CI, 0.54 to 0.99]; and parenting stress [B -0.45; 95% CI, -0.80 to -0.10]). Prolonged experiences had stronger associations with maternal health than shorter experiences.

CONCLUSION

Early childcare precarity has long-term adverse associations with maternal health, and emergency childcare support seems to be favorable for maternal health. These findings highlight childcare precarity as a social determinant of women's health for researchers, clinicians, and decision-makers.

Prescription for Cash? Cash Support to Low-Income Families in Maternal and Pediatric Health Care Settings

Policy Points Pregnancy and childhood are periods of heightened economic vulnerability, but current policies for addressing health-related social needs, including screening and referral programs, may be insufficient because of persistent gaps, incomplete follow-up, administrative burden, and limited take-up. To bridge gaps in the social safety net, direct provision of cash transfers to low-income families experiencing health challenges during pregnancy, infancy, and early childhood could provide families with the flexibility and support to enable caregiving, increase access to health care, and improve health outcomes.

Role of Effective Policy and Screening in Managing Pediatric Nutritional Insecurity as the Most Important Social Determinant of Health Influencing Health Outcomes

Social Determinants of Health (SDOH) impact nearly half of health outcomes, surpassing the influence of human behavior, clinical care, and the physical environment. SDOH has five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context. Any adversity arising out of these interlinked domains predominantly affects children due to their greater susceptibility, and the adverse outcomes may span generations. Unfavorable SDOH may cause food insecurity, malnutrition, unbalanced gut microbiome, acute and chronic illnesses, inadequate education, unemployment, and lower life expectancy. Systematic screening by health care workers and physicians utilizing currently available tools and questionnaires can identify children susceptible to adverse childhood experiences, but there is a deficiency with respect to streamlined approach and institutional support. Additionally, current ameliorating supplemental food programs fall short of pediatric nutritional requirements. We propose a nutrition-based Surveillance, Screening, Referral, and Reevaluation (SSRR) plan encompassing a holistic approach to SDOH with a core emphasis on food insecurity, coupled with standardizing outcome-based interventions. We also propose more inclusive use of Food Prescription Programs, tailored to individual children's needs, with emphasis on education and access to healthy food.

Monitoring Social Determinants of Health Assessing Patients and Communities

Because of the devastating health effects of social determinants of health (SDoH), it is important for the primary care provider to assess and monitor these types of stressors. This can be done via surveys, geomapping, or various biomarkers. To date, however, each of these methods is fraught with obstacles. There are currently are no validated "best" SDoH screening tools for use in clinical practice. Nor is geomapping, a perfect solution. Although mapping can collect location specific factors, it does not account for the fact that patients may live in one area, work in another and travel frequently to a third.

Social Determinants of Health: An Overview for the Primary Care Provider

Social determinants of health (SDoH) are reflected in how people live (access to health care, economic stability, built environment, food security, climate), learn (the educational environment), work (occupational environment), and play/socialize (social context and digital domain). All of these day-to-day conditions play a vital role in a patient's overall health, and a primary care provider should be prepared to understand their role to screen, assess, and address SDoH in clinical practice.

Screening for the social determinants of health: Referring patients to community-based services

BACKGROUND

Screening patients for the social determinants of health (SDOH) allows clinicians to identify those needs and tailor referral efforts. Due to constraints on clinic time and monetary resources, a simple screening tool incorporated into existing clinic workflow increases its usefulness and impact.

LOCAL PROBLEM

Our free, nurse-led, mobile health clinic (MHC) needed an enhanced process or tool for screening patients for SDOH. The purpose of this quality-improvement project was to screen adult patients in the MHC for SDOH needs and to increase volunteer staff perceptions of their knowledge and confidence in referring patients to relevant community-based services.

METHODS

A screening process and tool was developed using guidelines from the Health Leads to identify patients' SDOH needs and related requests for assistance. The tool was introduced to and tested among volunteer staff through pretest/posttest surveys.

INTERVENTIONS

Patients who visited the clinic were screened for the SDOH within the project period, and volunteer staff were surveyed about their perceptions of the screening tool.

RESULTS

Sixty-four patients were screened for SDOH needs. Twenty-three percent reported food insecurity, 27% housing insecurity, 14% difficulty obtaining utilities, and 17% difficulty obtaining transportation; 28% requested assistance with their reported SDOH needs. Seventeen percent of patients reported two or more SDOH needs. At posttest, 100% of volunteer staff ( N = 9) indicated satisfaction with the SDOH screening questions, reported feeling knowledgeable about resources to use for patient referrals, and were confident in referring patients to needed resources.

CONCLUSION

The screening tool aptly guided practice and was evaluated as "easy to use" for clinic patients and volunteer staff.

Making ends meet - relating a self-reported indicator of financial hardship to health status

BACKGROUND

Area-based index of multiple deprivation (IMD) indicators of financial hardship lack individual specificity and sensitivity. This study compared self-reports of hardship with area measures in relation to health status.

METHODS

Interviews in one London Borough, reported financial hardship and health status. Associations of health status with most and least deprived quintiles of the IMD 2015 were compared with self-reported hardship; always or sometimes 'having difficulty making ends meet at the end of the month' in relation to never.

RESULTS

1024 interviews reported hardship status in 1001 (98%). 392 people (39%) reported they 'always' or 'sometimes' had hardship. In multivariate analysis, self-reported hardship was more strongly associated with smoking; odds ratio = 5.4 (95% CI: 2.8-10.4) compared with IMD, odds ratio = 1.9 (95% CI: 1.2-3.2). Health impairment was also more likely with self-reported hardship, odds ratio = 11.1 (95% CI: 4.9-25.4) compared with IMD; odds ratio = 2.7 (95% CI: 1.4-5.3). Depression was similarly related; odds ratio = 2.4 (95% CI: 1.0-5.6) and 2.7 (95% CI: 1.2-6.6), respectively.

CONCLUSIONS

Self-reported hardship was more strongly related to health status than area-based indicators. Validity and implementation in routine health care settings remains to be established.

Patient comfort discussing sensitive behavioral health topics

BACKGROUND

: Following implementation of routine screening for depression in primary care, screening for other behavioral health issues is expanding. However, prior to implementing additional screening it is important to consider patient comfort answering sensitive questions related to behavioral health topics to determine screening acceptability and effectiveness.

METHODS

: A self-report survey was completed by U.S. adults over the age of 18 (n = 378) using Amazon Mechanical Turk. The survey assessed comfort discussing demographics, physical health, behavioral health, oral health, and living conditions with medical providers. Comfort levels of behavioral health topics were compared to comfort discussing depression symptoms and reasons for discomfort discussing topics were also surveyed.

RESULTS

: There were significant differences in comfort level discussing various behavioral health issues (F(8) = 51.70, P < .001). Participants reported being more comfortable discussing cigarette smoking and less comfortable discussing trauma, intimate partner violence (IPV) and gun ownership compared to depression. Privacy and perceived irrelevance were the most common reasons for discomfort.

CONCLUSIONS

: Accurate indices of patient behavioral health are essential for patient care. However, patients may be uncomfortable discussing some topics such as trauma, IPV, and gun ownership that patients view as private and/or unrelated to their treatment. Patient comfort may increase through provider trainings that focus on communication skills training, clear administrative procedures that allow for privacy and adequate time for discussions, and community education that underscores how these issues impact physical health.

Unmet Social Needs and Pediatric Asthma Severity in an Urban Primary Care Setting

OBJECTIVE

Community-level social determinants of health impact asthma outcomes among children; however, individual patient's priorities are not often included in designing social care interventions. Identifying connections between patient-prioritized unmet social needs and asthma severity status may allow for improved patient-centered approaches to asthma management. In this analysis, we examined the association between unmet social needs and asthma severity in an urban population of children. We hypothesized that those with a greater number of unmet social needs would report a more severe asthma status.

METHODS

We conducted a secondary analysis of 4887 patients screened for unmet social needs and asthma severity status. Bivariate associations and adjusted logistic regression modeling were used to assess the association between unmet social needs and asthma severity.

RESULTS

Persistent asthma severity status was associated with several unmet social needs, including housing quality and stability, lack of money for food, transportation, and healthcare costs. In the multivariable analysis, having 3 or more unmet social needs was associated with a 59% greater odds of persistent asthma status (CI, 1.18-2.14; P = .002), and having 2 unmet social needs was associated with a 33% greater odds of persistent asthma status (CI, 1.00-1.78; P = .05).

CONCLUSIONS

Unmet social needs were associated with asthma severity status, with a greater number of unmet social needs associated with greater odds of severe asthma status. Additional studies are warranted to further evaluate the temporal relationship between unmet social needs and how they may compound one another in their relationship with asthma severity.

Defining and Promoting Pediatric Pulmonary Health: Equitable Family and Community Partnerships

Optimizing pulmonary health across the lifespan begins from the earliest stages of childhood and requires a partnership between the family, pulmonologist, and pediatrician to achieve equitable outcomes. The Community Pediatrics session of the Defining and Promoting Pediatric Pulmonary Health workshop weaved together 4 community-based pillars with 4 research principles to set an agenda for future pediatric pulmonary research in optimizing lung and sleep health for children and adolescents. To address diversity, equity, and inclusion, both research proposals and workforce must purposefully include a diverse set of participants that reflects the community served, in addition to embracing nontraditional, community-based sites of care and social determinants of health. To foster inclusive, exploratory, and innovative research, studies must be centered on community priorities, with findings applied to all members of the community, particularly those in historically marginalized and minoritized groups. Research teams should also foster meaningful partnerships with community primary care and family members from study conceptualization. To achieve these goals, implementation and dissemination science should be expanded in pediatric pulmonary research, along with the development of rapid mechanisms to disseminate best practices to community-based clinicians. To build cross-disciplinary collaboration and training, community-academic partnerships, family research partnerships, and integrated research networks are necessary. With research supported by community pillars built on authentic partnerships and guided by inclusive principles, pediatric lung and sleep health can be optimized for all children and adolescents across the full lifespan in the community in which they live and thrive.

Addressing Social Determinants of Health in Practice

This review summarizes the current pediatric literature related to social determinants of health, including strengths and weaknesses of screening practices and intervention strategies, common concerns and potential unintended consequences, opportunities for further research, and provides evidence-informed practical strategies for clinicians.

Insurance Status and Tumor Necrosis Factor Inhibitor Initiation Among Children With Juvenile Idiopathic Arthritis in the CARRA Registry

OBJECTIVE

Prompt escalation to tumor necrosis factor inhibitors (TNFis) is recommended for children with juvenile idiopathic arthritis (JIA) and ongoing disease activity despite treatment with conventional disease-modifying antirheumatic drugs (cDMARDs). It is unknown whether these recommendations are equitably followed for children with different insurance types. We assessed the association of insurance coverage on the odds and timing of TNFi use.

METHODS

We conducted a retrospective study of children with newly diagnosed JIA in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. We compared the odds of starting a TNFi in the first year and time from cDMARD to TNFi initiation between those with public and private insurance.

RESULTS

We identified 1086 children with new JIA diagnoses. Publicly insured children had significantly higher active joint counts and parent/patient global assessment scores at the enrollment visit. They were also more likely to have polyarticular arthritis compared to those with private insurance. Odds of any TNFi use in the first year did not differ between publicly and privately insured children. Publicly insured children were escalated from cDMARD to TNFi more quickly than privately insured children.

CONCLUSION

Children who were publicly insured had more severe disease and polyarticular involvement at registry enrollment compared to those who were privately insured. Whereas overall TNFi use did not differ between children with different insurance types, publicly insured children were escalated more quickly, consistent with their increased disease severity. Further research is needed to determine why insurance coverage type is associated with disease severity, including how other socioeconomic factors affect presentation to care.

Pursuing a Cross-Sector Approach to Advance Child Health Equity

Cross-sector partnerships are essential to ensure a safe and effective system of care for children, their caregivers, and communities. A "system of care" should have a well-defined population, vision, and measures shared by health care and community stakeholders, and an efficient modality for tracking progress toward better, more equitable outcomes. Effective partnerships could be clinically integrated, built atop coordinated awareness and assistance, and community-connected opportunities for networked learning. As opportunities for partnership continue to be uncovered, it will be vital to broadly assess their impact, using clinical and nonclinical metrics.

Appropriate inhaler use in children with asthma: barriers and opportunities through the lens of the socio-ecological model

Objective: Proper use of inhaled medications is essential for management of asthma, as inhaled therapies are recommended as first-line for both prevention and treatment of asthma symptoms. Optimizing adherence requires identifying and understanding multiple layers of systemic complexity to obtaining and using these therapies and offering specific solutions to address these barriers. Bronfenbrenner's socio-ecological model provides a framework for examining multilevel systems - both internal and external - that contribute to the management of childhood asthma. The four levels in this model consist of factors related to the individual, interpersonal relationships, organizational entities, and societal structures and rules. This narrative review identifies influences and factors related to asthma inhaler adherence by each level and offers evidence-based solutions to each obstacle.Data Sources: We conducted PubMed searches to identify relevant articles for barriers and solutions impacting asthma control at each level of the socio-ecological model.Study Selection: Common barriers to asthma control at each model level were identified. Pertinent studies for each barrier were identified and reviewed by the writing group for inclusion into the narrative review.Results: For each level of the socio-ecological model, three primary issues were identified based on the literature review. Approaches for addressing each issue in an evidence-based, systematic fashion are presented.Conclusion: Understanding the obstacles and potential interventions to achieve proper use of inhaled medications is a critical step necessary to develop and implement systematic solutions aimed at improving asthma control and morbidity for the more than 6 million affected children in the United States.

Parent Preferences on Screening for Social Determinants of Health in Hospitalized Children

BACKGROUND

Although there has been much research on screening families for social determinants of health (SDOH) at pediatric outpatient visits, there is little data on family preferences about SDOH screening during hospitalization. This is of critical importance because unmet SDOH, also known as social needs, are associated with poor health outcomes.

OBJECTIVE

Our objective was to assess caregiver preferences for social needs screening in the inpatient pediatric setting.

METHODS

We surveyed a sample of caregivers of admitted patients at our freestanding tertiary-care children's hospital between March 2021 and January 2022. Caregivers were surveyed with respect to the importance of screening, their comfort with screening, and which domains were felt to be acceptable for screening.

RESULTS

We enrolled 160 caregivers. More than 60% of caregivers were comfortable being screened for each of the social needs listed. Between 40% and 50% found screening acceptable, even if resources were unavailable. Forty-five percent preferred to be screened in private, 9% preferred to be screened by a health care team member, and 37% were comfortable being screened either in private or with a health care team member. Electronic screening was the most preferred modality (44%), and if by a health care team member, social workers were preferred over others.

CONCLUSIONS

Many caregivers reported the acceptance of and comfort with social needs screening in the inpatient setting. Our findings may help inform future hospital-wide social needs screening efforts.

Model of psychosocial determinants of health in processes of social exclusion

The substantial increase in the number of families facing social exclusion in Europe and its direct relationship with health inequities is a challenge for studies approaching the social determinants of health and policies dealing with welfare and social inclusion. We start from the premise that reducing inequality (SDG10), has a value and contributes on other goals such as improving health and well-being (SDG3), ensuring quality education (SDG4), promoting gender equality (SDG5) and decent work (SDG8). In this study, we identify disruptive risk factors and psychological and social well-being factors that influence self-perceived health in trajectories of social exclusion. The research materials used a checklist of exclusion patterns, life cycles and disruptive risk factors, Goldberg's General Health Questionnaire (GHQ-12), Ryff's Psychological Well-being (PWB) Scale and Keyes' Social Well-being Scale. The sample consists of 210 people (aged between 16 and 64  years): 107 people in a situation of social inclusion and 103 people in a situation of social exclusion. The data treatment involved statistical analysis, including correlation study and multiple regression analysis, aimed at developing a model of psychosocial factors that may act as health modulators, considering social factors as predictors in the regression model. The results showed that individuals in the sample, in a situation of social exclusion, have a greater accumulation of disruptive risk factors, and these are related to having fewer psychosocial and cognitive resources to cope with stressful situations: less self-acceptance, less mastery of the environment, less purpose in life, less level of social integration and social acceptance. Finally, analysis showed that in the absence of social integration and purpose in life, self-perceived health statuses decline. This work allows us to use the model obtained as a basis for confirming that there are dimensions of psychological and social well-being that should be considered stress-buffering factors in trajectories of social exclusion. These findings can help design psychoeducational programs for prevention and intervention with the aim of improving psychological adjustment and health states, as well as to promote proactive and reactive policies to reduce health inequalities.

Social Determinants of Health: Implications for Voice Disorders and Their Treatment

PURPOSE

Adverse childhood experiences (ACEs) and related conditions, such as discrimination, are social determinants of health (SDOHs). Critical race theory (CRT) is a lens through which to understand SDOHs in a way that may impact our clinical care. When prolonged or chronic, SDOHs might cause toxic stress and trauma, which, in turn, adversely affect health and are shown to be relevant for some voice disorders. The goals of this tutorial are to (a) review the literature on SDOHs that potentially contribute to disparities; (b) discuss explanatory models and theories that describe how psychosocial factors influence health; (c) relate the foregoing information to voice disorders, highlighting functional voice disorders (FVDs) as a particular case in point; and (d) describe how trauma-informed care can improve patient outcomes and advance health equity for vulnerable populations.

CONCLUSIONS

This tutorial concludes with a call for heightened awareness of the role that SDOHs such as structural and individual discrimination may play in voice disorders, and a call for research into SDOHs, traumatic stress, and health disparities in this patient population. A call is also made for more universal practice of trauma-informed care in the clinical voice domain.

Supporting early childhood routines to promote cardiovascular health across the life course

Optimal cardiovascular health is an essential component of human health and well-being across the life course. Heart healthy practices around diet, physical activity, and sleep early in childhood have the potential to greatly improve lifespan and quality (Mehta et al., 2020). Early childhood routines, defined as functional practices that are predictable and repeatable, predict positive growth and development across the lifecourse (Fiese et al., 2002; Ferretti and Bub, 2017; Spagnola and Fiese, 2007). The American Heart Association has identified key heart healthy routines, such as daily regular activities including diet, physical activity, and sleep that promote cardiovascular health (Lloyd-Jones et al., 2022). Integrating the strength-based relational aspects of routines with the acquisition of cardiovascular health development capabilities allows children to establish their own optimal cardiovascular health trajectory early on. A systematic life course approach to supporting heart healthy routines in early childhood would inform clinical, research, and policy strategies to promote long-term cardiovascular health, and contribute to reducing inequalities in cardiovascular outcomes.

Athletic Trainers' Perceptions of and Experience with Social Determinants of Health

The role that social determinants of health (SDHs) play in athletic healthcare is gaining attention, yet little is known about athletic trainers' (ATs) perceptions of and encounters with the impact of SDHs. The purpose of this study was to evaluate ATs' perceptions of various SDHs and their experience treating patients whose health and well-being were influenced by SDHs. This was a cross-sectional, web-based survey completed by 1694 ATs (completion rate = 92.6%; 61.1% female; age = 36.6 ± 10.8 years). The survey consisted of several multipart questions focusing on specific SDHs. Descriptive statistics were used to report frequencies and percentages. Results indicated widespread agreement that SDHs matter to patient health and are of concern in athletic healthcare. The SDHs that ATs most commonly reported encountering included lifestyle choices (n = 1306/1406; 93.0%), social support (n = 1185/1427; 83.0%), income (n = 1167/1502; 77.7%), and access to quality and timely healthcare (n = 1093/1420, 77.0%). The SDHs that ATs least commonly reported having experience with was governmental policy (n = 684/1411; 48%). The perceived importance of SDHs among ATs and their commonly reported experiences managing patient cases in which SDHs negatively influence patients' health and healthcare suggest that efforts to assess these factors are needed so that strategies to address their influence on athletic healthcare can be identified.

Evictions and Infant and Child Health Outcomes: A Systematic Review

Importance

Millions of rental evictions occur in the United States each year, disproportionately affecting households with children. Increasing attention has been paid to the impact of evictions on child health outcomes.

Objective

To synthesize and assess studies examining the associations of eviction exposure with infant and child health outcomes.

Evidence Review

For this systematic review without meta-analysis, a database search was performed using PubMed, Web of Science, and PsycINFO, through September 25, 2022. Included studies were peer-reviewed quantitative studies examining an association between exposure to eviction and at least 1 health outcome, both before age 18 years, including prenatal exposures and perinatal outcomes. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data were analyzed from March 3 to December 7, 2022.

Findings

Database searches identified 266 studies, and 11 studies met inclusion criteria. Six studies examined associations between prenatal eviction and birth outcomes, such as gestational age, and each found that eviction was significantly associated with at least 1 adverse birth outcome. Five studies investigated other childhood outcomes, including neuropsychological test scores, parent-rated child health, lead testing rates, and body mass index, and among these 5 studies, 4 reported an association between eviction and adverse child health outcomes. Direct experience of eviction or residence in a neighborhood with more evictions was associated with adverse perinatal outcomes in 6 studies, higher neurodevelopmental risk in 2 studies, worse parent-rated child health in 2 studies, and less lead testing in 1 study. Study designs and methods were largely robust.

Conclusions and Relevance

In this systematic review without meta-analysis of the association between evictions and child health outcomes, evidence demonstrated the deleterious associations of eviction with a range of developmental periods and domains. In the context of a rental housing affordability crisis, ongoing racial disparities in evictions, and continuing harm to millions of families, health care practitioners and policy makers have an integral role to play in supporting safe, stable housing for all.

Impact of social disparities on 10 year survival rates in paediatric cancers: a cohort study

Background

Studies reporting on the impact of social determinants of health on childhood cancer are limited. The current study aimed to examine the relationship between health disparities, as measured by the social deprivation index, and mortality in paediatric oncology patients using a population-based national database.

Methods

In this cohort study of children across all paediatric cancers, survival rates were determined using the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2016. The social deprivation index was used to measure and assess healthcare disparities and specifically the impact on both overall and cancer-specific survival. Hazard ratios were used to assess the association of area deprivation.

Findings

The study cohort was composed of 99,542 patients with paediatric cancer. Patients had a median age of 10 years old (IQR: 3-16) with 46,109 (46.3%) of female sex. Based on race, 79,984 (80.4%) of patients were identified as white while 10,801 (10.9%) were identified as Black. Patients from socially deprived areas had significantly higher hazard of death overall for both non-metastatic [1.27 (95% CI: 1.19-1.36)] and metastatic presentations [1.09 (95% CI: 1.05-1.15)] compared to in more socially affluent areas.

Interpretation

Patients from the most socially deprived areas had lower rates of overall and cancer-specific survival compared to patients from socially affluent areas. With an increase in childhood cancer survivors, implementation of social determinant indices, such as the social deprivation index, might aid improvement in healthcare outcomes for the most vulnerable patients.

Funding

There was no study sponsor or extramural funding.

Implementing Social Risk Screening and Referral to Resources in the NICU

OBJECTIVE

Social risk screening is recommended by the American Academy of Pediatrics, but this practice is underutilized in NICUs. To address this gap in social care, we aimed to increase rates of: (1) systematic social risk screening and (2) connection with community resources, each to ≥50% over a 14-month period.

METHODS

We conducted a quality improvement initiative from November 2020 to January 2022. We adapted a screening tool and used Plan-Do-Study-Act cycles to integrate screening and referral to resources into clinical workflow. Primary outcome measures included the percentage of (1) families screened and (2) connection with resources. We examined screening by maternal race/ethnicity and primary language. Process measures were (1) time from admission to screening and (2) percentage of referrals provided to families reporting unmet needs and requesting assistance. We used statistical process control to assess change over time and χ2 tests to compare screening by race/ethnicity and language.

RESULTS

The rates of systematic screening increased from 0% to 49%. Among 103 families screened, 84% had ≥1, and 64% had ≥2 unmet needs, with a total of 221 needs reported. Education, employment, transportation, and food were the most common needs. Screening rates did not vary by race/ethnicity or language. Among families requesting assistance, 98% received referrals. The iterative improvement of a written resource guide and community partnerships led to increased rates of connection with resources from 21% to 52%.

CONCLUSION

Leveraging existing staff, our social risk screening and referral intervention built the capacity to address the high burden of unmet needs among NICU families.

A feasibility and acceptability study of screening the parents/guardians of pediatric dental patients for the social determinants of health

BACKGROUND

The social determinants of health (SDOH) are the conditions in which people are born, grow, work, live, and age. Lack of SDOH training of dental providers on SDOH may result in suboptimal care provided to pediatric dental patients and their families. The purpose of this pilot study is to report the feasibility and acceptability of SDOH screening and referral by pediatric dentistry residents and faculty in the dental clinics of Family Health Centers at NYU Langone (FHC), a Federally Qualified Health Center (FQHC) network in Brooklyn, NY, USA.

METHODS

Guided by the Implementation Outcomes Framework, 15 pediatric dentists and 40 pediatric dental patient-parent/guardian dyads who visited FHC in 2020-2021 for recall or treatment appointments participated in this study. The a priori feasibility and acceptability criteria for these outcomes were that after completing the Parent Adversity Scale (a validated SDOH screening tool), ≥ 80% of the participating parents/guardians would feel comfortable completing SDOH screening and referral at the dental clinic (acceptable), and ≥ 80% of the participating parents/guardians who endorsed SDOH needs would be successfully referred to an assigned counselor at the Family Support Center (feasible).

RESULTS

The most prevalent SDOH needs endorsed were worried within the past year that food would run out before had money to buy more (45.0%) and would like classes to learn English, read better, or obtain a high school degree (45.0%). Post-intervention, 83.9% of the participating parents/guardians who expressed an SDOH need were successfully referred to an assigned counselor at the Family Support Center for follow-up, and 95.0% of the participating parents/guardians felt comfortable completing the questionnaire at the dental clinic, surpassing the a priori feasibility and acceptability criteria, respectively. Furthermore, while most (80.0%) of the participating dental providers reported being trained in SDOH, only one-third (33.3%) usually or always assess SDOH for their pediatric dental patients, and most (53.8%) felt minimally comfortable discussing challenges faced by pediatric dental patient families and referring patients to resources in the community.

CONCLUSIONS

This study provides novel evidence of the feasibility and acceptability of SDOH screening and referral by dentists in the pediatric dental clinics of an FQHC network.

A One Welfare approach to identify socioeconomic vulnerability in families during investigations into companion animal abuse in Pinhais, Brazil

A One Welfare approach allows intervention to resolve problems related to the human-animal-environment interface. However, in Brazil and many other countries, there is poor communication between human and animal welfare services. In this research we considered a One Welfare approach in cases of abuse involving dogs and cats. When investigating pet abuse, professionals from the Animal Welfare Division of Pinhais, Brazil, can enter the home environment. During routine animal abuse investigations, the demographic profile of pet owners and their socioeconomic vulnerability was also recorded. Results from forty-five cases with (n = 30) and without (n = 15) suspicion of socioeconomic vulnerability were sent to the Department of Social Assistance of Pinhais, Brazil for confirmation. Socioeconomic vulnerability was suspected if socioeconomic problems were reported by the pet owners under investigation or their neighbours, as well by assessment of the socioeconomic environment of the families during home visits. Economic disadvantage was the most prevalent socioeconomic vulnerability. Cohen's Kappa coefficients support the ability of animal welfare service professionals to detect socioeconomic vulnerability. Almost half of all families considered to have socioeconomic vulnerability had not previously participated in social programmes. In all cases involving families already being assisted by the Department of Social Assistance, pets were found to be suffering abuse. Families with socioeconomic vulnerability confirmed were included in the social programmes. These results support the need for a multi-disciplinary approach to improve the well-being of families with dogs and cats. This study can help guide the development of an interdisciplinary approach to address animal abuse cases.

"Why Do They Want to Know?": A Qualitative Assessment of Caregiver Perspectives on Social Drivers of Health Screening in Pediatric Primary Care

OBJECTIVE

Despite strong evidence that social factors have a large influence on child health, systematic screening for social needs is not performed universally in pediatric primary care. This is due to multiple barriers, including concerns about acceptability to families. This study sought to assess family acceptability of social needs screening in pediatric primary care.

METHODS

Eight semi-structured focus groups were performed with English and Spanish-speaking caregivers of pediatric patients from a diverse academic medical center. Focus groups explored the acceptability of social domains including housing, education, finances, food access, and safety. Focus group transcripts were qualitatively analyzed to identify themes.

RESULTS

Four salient themes emerged: 1) the acceptability of social determinants of health screening questions was tied to participants' understanding of the connection between the topic and child health, 2) families preferred a warm handoff to community services, 3) families feared child protective services intervention as a result of sharing unmet social needs, and 4) positive provider rapport was an important factor in choosing to share social needs.

CONCLUSIONS

Pediatric primary care providers should feel comfortable implementing social needs screening when they can clearly explain the connection to child health. They should become knowledgeable about organizations and partners within their communities and feel empowered to connect patients to these resources.

Clinical Pathways for the Identification and Referral for Social Needs: A Systematic Review

CONTEXT

Recognition of the importance of the social determinants of child health has prompted increased interest in clinical pathways that identify and refer for social needs.

OBJECTIVE

The aim of this systematic review was to determine the effectiveness of interventions that identify and refer for social needs for families with children aged 0 to 18 years attending outpatient community and ambulatory healthcare services.

DATA SOURCES

We searched the following databases: Medline, Embase, PsychINFO, CINAHL, Emcare, EBMR.

STUDY SELECTION

Studies were included if children and their families underwent a process of identification and referral for social needs in outpatient community and ambulatory healthcare services.

DATA EXTRACTION

Initial searches identified 5490 titles, from which 18 studies (73 707 families and children) were finally retained.

RESULTS

Intervention pathways were grouped into 3 categories based on whether identification and referral for social needs was conducted with only targeted community resources, a navigator, or with clinician training. The majority of studies reported positive outcomes; with an increase in social needs identification, an increase in referrals following identification, or a reduction in social needs. Child health outcome results were inconsistent.

LIMITATIONS

The search terms used may have provided bias toward countries in which these terms are in use. The heterogeneity of outcome measures between included studies meant a meta-analysis was not possible.

CONCLUSIONS

Despite evidence that clinical pathways for children and families help reduce social needs, evidence for improvements in child health is insufficient. Further studies from diverse settings are needed to inform clinical practice to optimize child health outcomes.

Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches

Alcohol is legalized and used for a variety of reasons, including socially or as self-medication for trauma in the absence of accessible and safe supports. Trauma-informed approaches can help address the root causes of alcohol use, as well as the stigma around women's alcohol use during pregnancy. However, it is unclear how these approaches are used in contexts where pregnant and/or parenting women access care. Our objective was to synthesize existing literature and identify promising trauma-informed approaches to working with pregnant and/or parenting women who use alcohol. A multidisciplinary team of scholars with complementary expertise worked collaboratively to conduct a rigorous scoping review. All screening, extraction, and analysis was independently conducted by at least two authors before any differences were discussed and resolved through team consensus. The Joanna Briggs Institute method was used to map existing evidence from peer-reviewed articles found in PubMed, CINAHL, PsycINFO, Social Work Abstracts, and Web of Science. Data were extracted to describe study demographics, articulate trauma-informed principles in practice, and gather practice recommendations. Thirty-six studies, mostly from the United States and Canada, were included for analysis. Studies reported on findings of trauma-informed practice in different models of care, including live-in treatment centers, case coordination/management, integrated and wraparound supports, and outreach-for pregnant women, mothers, or both. We report on how the following four principles of trauma-informed practices were applied and articulated in the included studies: (1) trauma awareness; (2) safety and trustworthiness; (3) choice, collaboration, and connection; and (4) strengths-based approach and skill building. This review advances and highlights the importance of understanding trauma and applying trauma-informed practice and principles to better support women who use alcohol to reduce the risk of alcohol-exposed pregnancies. Relationships and trust are central to trauma-informed care. Moreover, when applying trauma-informed practices with pregnant and parenting women who use alcohol, we must consider the unique stigma attached to alcohol use.

Social Needs Screening in Hospitalized Pediatric Patients: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

Addressing adverse social determinants of health is an upstream approach to potentially improve child health outcomes and health equity. We aimed to determine if systematically screening and referring for social needs in hospitalized pediatric patients increased families' enrollment in publicly available resources.

METHODS

Randomized controlled trial at a large urban children's hospital enrolled English-speaking caregivers of patients 0 to 36 months of age on the general pediatrics service from June 2016 to July 2017. The intervention arm received the WE CARE Houston social needs intervention (screener and resource referrals based on screening results and receptiveness to help); the control arm received standard of care. Baseline social risk data were collected for all participants. Caregivers who screened positive for mental health need, substance abuse, or domestic violence received additional support, including from social workers. The primary outcome was enrollment in resources at 6 months postdischarge. Univariate and multivariable analysis was performed to identify associations.

RESULTS

Our study sample consisted of 413 caregivers from diverse sociodemographic/socioeconomic backgrounds. Overall, 85% of study participants had ≥1 social risk (median 2, range 0-9). WE CARE Houston identified caregiver employment, health insurance, primary care physician, depression, childcare, smoking, and food resources as the most prevalent social needs. Among these, caregivers were most receptive to resources for childcare, mental health, health insurance, and primary care. There was no significant difference in enrollment in new resources by study arm.

CONCLUSION

Screening for social needs in the hospital is feasible and can result in the identification of social needs, but further work is needed to successfully address these needs.

Recognizing Our Biases, Understanding the Evidence, and Responding Equitably: Application of the Socioecological Model to Reduce Racial Disparities in the NICU

BACKGROUND

Implicit bias permeates beliefs and actions both personally and professionally and results in negative health outcomes for people of color-even in the neonatal intensive care unit (NICU). NICU clinicians may naïvely and incorrectly assume that NICU families receive unbiased care. Existing evidence establishing associations between sex, race, and neonatal outcomes may perpetuate the tendency to deny racial bias in NICU practice.

EVIDENCE ACQUISITION

Using the socioecological model as a framework, this article outlines evidence for racial health disparities in the NICU on multiple levels-societal, community, institutional, interpersonal, and individual. Using current evidence and recommendations from the National Association of Neonatal Nurses Position Statement on "Racial Bias in the NICU," appropriate interventions and equitable responses of the NICU clinician are explored.

RESULTS

Based on current evidence, clinicians should reject the notion that the social construct of race is the root cause for certain neonatal morbidities. Instead, clinicians should focus on the confluence of medical and social factors contributing to each individual infant's progress. This critical distinction is not only important for clinicians employing life-saving interventions, but also for those who provide routine care, developmental care, and family education-as these biases can and do shape clinical interactions.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Healthcare practitioners have an ethical and moral responsibility to maintain up-to-date knowledge of new evidence that impacts our clinical practice. The evidence demonstrates the importance of recognizing the enduring role of racism in the health and well-being of people of color and the need to adjust care accordingly.

Assessment of Social Vulnerability in Pediatric Head and Neck Cancer Care and Prognosis in the United States

IMPORTANCE

Prior investigations in social determinants of health (SDoH) in pediatric head and neck cancer (HNC) have only considered a narrow scope of HNCs, SDoH, and geography while lacking inquiry into the interrelational association of SDoH with disparities in clinical pediatric HNC.

OBJECTIVES

To evaluate the association of SDoH with disparities in HNC among children and adolescents and to assess which specific aspects of SDoH are most associated with disparities in dynamic and regional sociodemographic contexts.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included data about patients (aged ≤19 years) with pediatric HNC who were diagnosed from 1975 to 2017 from the Surveillance, Epidemiology, and End Results Program (SEER) database. Data were analyzed from October 2021 to October 2022.

EXPOSURES

Overall social vulnerability and its subcomponent contributions from 15 SDoH variables, grouped into socioeconomic status (SES; poverty, unemployment, income level, and high school diploma status), minority and language status (ML; minoritized racial and ethnic group and proficiency with English), household composition (HH; household members aged ≥65 and ≤17 years, disability status, single-parent status), and housing and transportation (HT; multiunit structure, mobile homes, crowding, no vehicle, group quarters). These were ranked and scored across all US counties.

MAIN OUTCOMES AND MEASURES

Regression trends were performed in continuous measures of surveillance and survival period and in discrete measures of advanced staging and surgery receipt.

RESULTS

A total of 37 043 patients (20 729 [55.9%] aged 10-19 years; 18 603 [50.2%] male patients; 22 430 [60.6%] White patients) with 30 different HNCs in SEER had significant relative decreases in the surveillance period, ranging from 23.9% for malignant melanomas (mean [SD] duration, lowest vs highest vulnerability: 170 [128] months to 129 [88] months) to 41.9% for non-Hodgkin lymphomas (mean [SD] duration, lowest vs highest vulnerability: 216 [142] months vs 127 [94] months). SES followed by ML and HT vulnerabilities were associated with these overall trends per relative-difference magnitudes (eg, SES for ependymomas and choroid plexus tumors: mean [SD] duration, lowest vs highest vulnerability: 114 [113] months vs 86 [84] months; P < .001). Differences in mean survival time were observed with increasing social vulnerability, ranging from 11.3% for ependymomas and choroid plexus tumors (mean [SD] survival, lowest vs highest vulnerability: 46 [46] months to 41 [48] months; P = .43) to 61.4% for gliomas not otherwise specified (NOS) (mean [SD] survival, lowest vs highest vulnerability: 44 [84] months to 17 [28] months; P < .001), with ML vulnerability followed by SES, HH, and HT being significantly associated with decreased survival (eg, ML for gliomas NOS: mean [SD] survival, lowest vs highest vulnerability: 42 [84] months vs 19 [35] months; P < .001). Increased odds of advanced staging with non-Hodgkin lymphoma (OR, 1.21; 95% CI, 1.02-1.45) and retinoblastomas (OR, 1.31; 95% CI, 1.14-1.50) and decreased odds of surgery receipt for melanomas (OR, 0.79; 95% CI, 0.69-0.91) and rhabdomyosarcomas (OR, 0.90; 95% CI, 0.83-0.98) were associated with increasing overall social vulnerability.

CONCLUSIONS AND RELEVANCE

In this cohort study of patients with pediatric HNC, significant decreases in receipt of care and survival time were observed with increasing SDoH vulnerability.

Social determinants of health screening in pediatric healthcare settings

PURPOSE OF REVIEW

This article outlines updates in social determinants of health (SDOH) screening practices in pediatric healthcare and community settings. The transition to value-based care and the COVID-19 pandemic have both had significant impacts on screening practices, with implications for providers, communities, and policymakers.

RECENT FINDINGS

The COVID-19 pandemic has exacerbated social needs for vulnerable patients and families, resulting in increased recognition by healthcare teams through screening. Policy frameworks like value-based care that aim to deliver whole-child care in the community are reorienting the logistics of screening, including screening in acute-care settings and community settings. Recent studies on family and provider perspectives should be integrated into screening practices.

SUMMARY

Despite significant advances in and expansion of SDOH screening in the pediatric healthcare setting, there remain limitations and future research needs. More data is needed to evaluate social need screeners and interventions, and determine how healthcare systems, communities, and states can spread and scale such interventions based on outcomes and value measurements. Population-based social indices have the potential to augment individual patient screening, but this remains a future research need.

Effect of Disease Severity, Age of Child, and Clinic No-Shows on Unscheduled Healthcare Use for Childhood Asthma at an Academic Medical Center

This study examines the influence of various individual demographic and risk factors on the use of unscheduled healthcare (emergency and inpatient visits) among pediatric outpatients with asthma over three retrospective timeframes (12, 18, and 24 months) at an academic health center. Out of a total of 410 children who visited an academic medical center for asthma outpatient care between 2019 and 2020, 105 (26%) were users of unscheduled healthcare for childhood asthma over the prior 12 months, 131 (32%) over the prior 18 months, and 147 (36%) over the prior 24 months. multiple logistic regression (MLR) analysis of the effect of individual risk factors revealed that asthma severity, age of child, and clinic no-shows were statistically significant predictors of unscheduled healthcare use for childhood asthma. Children with higher levels of asthma severity were significantly more likely to use unscheduled healthcare (compared to children with lower levels of asthma severity) across all three timeframes. Likewise, children with three to four clinic no-shows were significantly more likely to use unscheduled healthcare compared to children with zero clinic no-shows in the short term (12 and 18 months). In contrast, older children were significantly less likely to use unscheduled healthcare use compared to younger children in the longer term (24 months). By virtue of its scope and design, this study provides a foundation for addressing a need identified in the literature for short- and long-term strategies for improving supported self-management and reducing unscheduled healthcare use for childhood asthma at the patient, provider, and organizational levels, e.g., (1) implementing telehealth services for asthma outpatient care to reduce clinic no-shows across all levels of asthma severity in the short term; (2) developing a provider-patient partnership to enable patient-centered asthma control among younger children with higher asthma severity in the long term; and (3) identifying hospital-community linkages to address social risk factors influencing clinic no-shows and unscheduled healthcare use among younger children with higher asthma severity in the long term.

Investigation of health literacy status and related influencing factors in military health providers of Chinese People's liberation Army, a cross-sectional study

OBJECTIVE

The aim of this study was to investigate health literacy and analyze its influencing factors in military health providers of the Chinese People's Liberation Army (PLA Army).

METHODS

From November to December 2018, cluster sampling was used to select 1512 military health providers from the Army Medical University. Health literacy was measured by using the Chinese Citizen Health Literacy Questionnaire (HLQ) (2015 edition). Influencing factors that may affect health literacy were assessed using the chi-square test and multivariate logistic regression models.

RESULTS

The knowledge rate of health literacy was relatively low (21.6%). The knowledge rate of health-related skills (HRS, 18.7%) was the lowest of the three aspects of health literacy, and the knowledge rate of chronic diseases (CD, 19.6%) was the lowest of the six dimensions of health literacy. Participants who were older, were female, were of Han ethnicity, were the only child in their families, came from urban areas, never used tobacco, and had higher household income were likely to have higher health literacy.

CONCLUSION

The health literacy levels of military health providers of the PLA Army are relatively low. Further research and health education are necessary to improve health literacy.

The Impact of Adverse Childhood Experiences and Community Violence Exposure on a Sample of Anxious, Treatment-Seeking Children

Screening for adverse childhood experiences (ACEs) can help prevent and reduce adverse outcomes on child development, including increased risk for anxiety disorders. Emerging studies strongly support the inclusion of community-level adversities in ACE screeners to consider diverse contexts and populations. Recent studies suggest that community violence exposure (CVE) may have a distinct impact on youth mental health. Although recent studies have examined the association between ACEs, CVE, and mental health in primary care settings, this association has not been examined on treatment-seeking children in urban mental health settings. The present study employs a mediation model using the PROCESS macro to examine community violence exposure mediating the effect on the association between ACEs and somatic symptoms (SS) on a sample of anxious treatment-seeking children. A total of 98 participants (Mage = 11.7, SD = 3.79, 51.6% males, 54.1% ethnic minority children) who sought services at a specialized anxiety clinic completed self-report measures. Results indicated that exposure to ACEs is associated with endorsement of somatic symptoms as a result of reporting hearing, witnessing, or experiencing CVE. Evidence of mediation was found in a statistically significant indirect effect of ACEs on SS through CREV (Effect = .17, 95% CI = .069-.294). These findings support recent evidence that CVE is a distinct ACE as it contributes to toxic stress similar to individual-level ACEs. The use of a comprehensive ACE screening that includes CVE is warranted, particularly when working with culturally and socioeconomically diverse populations, as it would better capture a broader range of adversities across demographic groups.

Validation of a Script to Facilitate Social Determinant of Health Conversations with Adolescent Patients

Current social determinants of health (SDOH) tools exist to assess patient exposure; however, healthcare providers for the adolescent population are unsure of how to integrate SDOH knowledge into clinical practice. The purpose of this study was to validate a focused history script designed to facilitate SDOH conversations between clinicians and adolescents through the use of the Delphi method. Six individuals (1 clinician, 5 educators/researchers) participated as expert panelists. Panelists provided critical feedback on the script for rounds 1 and 2. For rounds 3-7, panelists received an electronic questionnaire asking them to indicate agreement on a 6-point Likert scale (1 = strongly disagree, 6 = strongly agree). We defined consensus as mean item agreement ≥ 5.0 and percent agreement ≥ 80%. In round 7, panelists rated overall script level of agreement. After seven rounds of feedback, the focused history script achieved content validity with 100% of panelists agreeing on the final 40-item script. A focused history script for the SDOH was content validated to aid conversations between healthcare providers and adolescent patients on factors that affect their life, school, and play. Addressing social determinants of health with adolescent patients will improve cultural proficiency and family-centered care delivered by school healthcare professionals.