Improving Child Health by Screening for Social Determinants

Review

Garg A, Toy S Tripodis Y, et al: Addressing Social Determinants of Health at Well Child Care Visits: A Cluster RCT. Pediatrics Feb 2015; 135(2): 296-304.

Study Methods

This cluster randomized controlled trial evaluated whether a screening and referral system for social determinants of health (called WE CARE) at well child visits resulted in receipt of more community resources for families.

In four community health centers in Boston MA, mothers of infants ≤6 months of age who were present for well child visits were asked to complete a screening questionnaire while in the waiting room that assessed for unmet basic needs. The questions topics included child care, parent education, employment, food security, housing, and household heating. Mothers were provided with resource referrals based on their needs. Four different community health centers in Boston served as controls, where mothers and infants received standard care including access to basic social work services. In both study arms, enrollment in new community-based resources was assessed at the child’s 12-month well visit.

Results

Greater than 90% of mothers reported at least one unmet basic need, 68% reported ≥2 needs, and 39% reported ≥3 needs at baseline. Seventy percent of mothers who were screened through WE CARE received at least one referral at their initial visit, compared with 8% of controls. At the 12-month visit, WE CARE mothers had greater odds of being enrolled in ≥1 new resource (adjusted OR 2.1), being employed or in a job training program (aOR=44.4), having child care (aOR=6.3), and receiving fuel assistance (aOR= 11.9). They also had lower odds of being in a homeless shelter (aOR 0.2). The number needed to treat for a family to receive a community resource referral was 1.6, and the NNT for a family to enroll in a new resource was 6.7.

Conclusion

Systematically screening for basic unmet needs and social determinants of health during well child visits and providing appropriate referrals leads to receipt of more community resources for families.

Discussion

The idea that social, economic, and environmental factors contribute to an individual’s overall health is not a new concept. Addressing these social determinants of health is one of primary care’s key roles. This is particularly true in the pediatric population, where financial resources, parental education and employment, home environment, and social support strongly influence a child’s growth, development, well-being and ultimately their role as a productive adult in society. However, finding a concrete or systematic way to effectively address social needs during a primary care visit can be challenging.

This study showed a simple screening and referral system successfully identified social needs, connected families with community resources, and led to an uptake of these resources. One of the arguments against addressing social determinants is a physicians’ limited time. However, this intervention consisted of only a 12-item questionnaire completed in the waiting room. Providers had to simply review the questionnaire with mothers and then provide information sheets and applications for appropriate resources. The efficacy of this intervention demonstrated the clinicians had to screen only 2 families to result in a referral, and only 7 families to result in receipt of a new resource.

One weakness of this study is it only evaluates unmet needs during a child’s first year of life. Though this is a critical period, families’ circumstances are dynamic and may change over time. Periodic screening may be found to be helpful in continuing to facilitate social well-bring throughout a child’s development. While this study’s relatively short follow up did demonstrate improved referrals and receipt of help, it failed to answer the critical question of whether initial enrollment in community resources translates into long-term benefits, like improved school performance, less malnutrition, and possibly lower risk for criminal involvement.

Overall, this study demonstrates an effective way to assess and address the social needs of children during well childcare. While many clinicians already address these issues less formally, a systematic tool can help ensure the social determinants are not overlooked in the context of hectic clinic schedules. The authors indicate their results are more “proof of principle” than evidence for a specific intervention. Other groups wishing to provide similar assistance to families will have to create programs that are tailored to their patient population and community.